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The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit
Christina L Cifra1, Kareen L Jones2, Judith Ascenzi3
1Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.
Insights
Standardized chart review in pediatric intensive care units (PICUs) identified more safety events than morbidity and mortality conferences (MMCs) alone. However, MMCs excel at uncovering systemic issues like communication errors, improving patient safety analysis.
Area of Science:
- Pediatric Intensive Care Medicine
- Patient Safety
- Healthcare Quality Improvement
Background:
- Morbidity and mortality conferences (MMCs) are crucial for reviewing patient safety events in pediatric intensive care units (PICUs).
- The effectiveness of standardized chart review in conjunction with MMCs for comprehensive safety event identification remains under investigation.
Purpose of the Study:
- To evaluate whether standardized chart review of patients discussed at PICU MMCs yields additional or different safety event information.
- To compare the types and characteristics of safety events identified by MMC alone versus chart review alone versus combined methods.
Main Methods:
- Retrospective record review of 96 patients discussed at a single tertiary referral PICU's MMC over 14 months.
- Identification and characterization of safety events, including medical error category, severity, and preventability.
Main Results:
- Standardized chart review identified 144 additional safety events (52%) not initially discovered through the MMC.
- The MMC alone was superior in identifying communication errors, workflow problems, and certain diagnostic errors.
- High-severity adverse events were more likely identified through combined MMC and chart review.
Conclusions:
- Standardized chart review significantly enhances the detection of safety events in PICU MMCs.
- MMCs remain vital for identifying broader systemic issues that impact patient care quality and safety.
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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