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PSNet: Patient Safety Network
Journal Article
Study

The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety.

Frey B, Doell C, Klauwer D, et al. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2016;17:67-72.

Interdisciplinary morbidity and mortality conferences were an effective way to identify system failures contributing to medical errors, in this report from a children's hospital in Switzerland. The study analyzed 48 morbidity and mortality conferences over a 5-year period and gives examples of the 34 system improvements that were put into place as a result.