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The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety
Bernhard Frey1, Carsten Doell, Dietrich Klauwer
1Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital, Zurich, Switzerland.
Insights
Interdisciplinary morbidity and mortality conferences identify medical errors and system vulnerabilities. This approach enhances patient safety by addressing diagnostic and communication issues in critical care settings.
Area of Science:
- Pediatric Critical Care Medicine
- Patient Safety Research
- Healthcare Quality Improvement
Background:
- Morbidity and Mortality (M&M) conferences are crucial for learning from adverse events.
- Implementing a structured, interdisciplinary approach can optimize M&M conference effectiveness.
- Previous M&M conference models may not fully capture system-based errors.
Purpose of the Study:
- To evaluate the utility of an interdisciplinary and interprofessional M&M conference in a pediatric intensive care unit (PICU).
- To emphasize the role of M&M conferences in improving patient safety.
- To identify specific types of medical errors and system issues revealed through the M&M process.
Main Methods:
- Retrospective analysis of M&M conference minutes from a tertiary interdisciplinary neonatal PICU.
- Review of 48 patient cases (newborns to 17 years) from January 2009 to June 2014.
- System-based approach to identify medical errors, contributing factors, and potential solutions.
Main Results:
- M&M conferences identified unsafe processes/medical errors in 77% of discussions.
- Interface problems were contributing factors in 30 of 50 identified errors.
- Fifty-four improvements were identified across 34 M&M conferences.
- Treatment complications were the primary reason for PICU admission in six cases.
Conclusions:
- Interdisciplinary M&M conferences effectively reveal system-based medical errors, including diagnostic and communication failures.
- A non-hierarchical M&M conference format encourages staff contributions, enhancing its role in error analysis.
- M&M conferences are vital for a systematic approach to improving patient safety in pediatric critical care.
Objectives:
To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety.
Design:
Retrospective analysis.
Setting:
Tertiary interdisciplinary neonatal PICU.
Patients:
Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014.
Interventions:
None.
Measurements And Main Results:
The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues.
Conclusions:
From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors.
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