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

Christina L Cifra; Kareen L Jones; Judith Ascenzi; Utpal S Bhalala; Melania M Bembea; James C Fackler; Marlene R Miller

Study

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

August 20, 2014

Cifra CL, Jones KL, Ascenzi J, et al. BMJ Qual Saf. 2014;23(11):930-8.

View more articles from the same authors.

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.

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

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