Journal Article

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

Cifra CL, Jones KL, Ascenzi J, et al. BMJ quality & safety. 2014;23:930-8.

In this study, applying standardized chart reviews for incidents discussed during morbidity and mortality conferences in a pediatric intensive care unit uncovered many previously unrecognized safety events. Conversely, the conferences revealed near misses and diagnostic errors that were not obvious in chart documentation.