@article{12079,
  author = {Bernhard Frey and Carsten Doell and Dietrich Klauwer and Vincenzo Cannizzaro and Vera Bernet and Christine Maguire and Barbara Brotschi},
  title = {The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety.},
  abstract = {<p><b>OBJECTIVES: </b>To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety.</p><p><b>DESIGN: </b>Retrospective analysis.</p><p><b>SETTING: </b>Tertiary interdisciplinary neonatal PICU.</p><p><b>PATIENTS: </b>Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014.</p><p><b>INTERVENTIONS: </b>None.</p><p><b>MEASUREMENTS AND MAIN RESULTS: </b>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.</p><p><b>CONCLUSIONS: </b>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.</p>},
  year = {2016},
  journal = {Pediatr Crit Care Med},
  volume = {17},
  pages = {67-72},
  month = {01/2016},
  issn = {1529-7535},
  doi = {10.1097/PCC.0000000000000550},
  language = {eng},
}