The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit

Christina L Cifra, Kareen L Jones, Judith Ascenzi, Utpal S Bhalala, Melania M Bembea, James C Fackler, Marlene R Miller
BMJ Quality & Safety 2014, 23 (11): 930-8

OBJECTIVE: To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics.

DESIGN: Retrospective record review.

SETTING: Single tertiary referral PICU in Baltimore, Maryland, USA.

PARTICIPANTS: 96 patients discussed at the PICU MMC over 14 months (November 2011-December 2012).

MAIN OUTCOME MEASURES: Safety events and their characteristics (medical error category, severity and preventability).

RESULTS: A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses.

CONCLUSIONS: Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.

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