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. The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit. BMJ Qual Saf. 2014;23(11):930-8. doi:10.1136/bmjqs-2014-003000.
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.