Transforming the morbidity and mortality conference to promote safety and quality in a PICU.

Christina L Cifra; Melania M Bembea; James C Fackler; Marlene R Miller

Study

Transforming the morbidity and mortality conference to promote safety and quality in a PICU.

April 6, 2016

Cifra CL, Bembea MM, Fackler JC, et al. Crit Care Med. 2016;17(1):58-66.

View more articles from the same authors.

Traditional morbidity and mortality conferences were designed to focus on educational opportunities to learn from medical errors. In this study, introducing a structured systems-oriented morbidity and mortality conference in a pediatric intensive care unit led to higher attendance rates and more proposed local quality improvement interventions.

PubMed citation

Available at

Related Resources From the Same Author(s)

The morbidity and mortality conference in PICUs in the United States: a national survey.

September 24, 2014

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

August 20, 2014

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.

August 14, 2019

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.

March 6, 2005

Tracking progress in patient safety: an elusive target.

August 16, 2006

Finding diagnostic errors in children admitted to the PICU.

February 8, 2017

Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture/laceration.

February 29, 2012

Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

February 16, 2011

Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database.

July 29, 2009

Measurement of quality and assurance of safety in the critically ill.

April 8, 2009

Prescribing errors in a pediatric emergency department.

March 5, 2008

Interventions to reduce pediatric medication errors: a systematic review.

July 30, 2014

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

April 18, 2007

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

June 13, 2007

Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.

February 8, 2012

State-mandated hospital infection reporting is not associated with decreased pediatric health care–associated infections.

September 9, 2015

Decreasing errors in pediatric continuous intravenous infusions.

May 24, 2006

Pediatric antidepressant medication errors in a national error reporting database.

February 17, 2010

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

Cardiovascular medication errors in children.

July 22, 2009

Medication errors in the ambulatory treatment of pediatric attention deficit hyperactivity disorder.

September 3, 2008

A national profile of patient safety in U.S. hospitals.

March 6, 2005

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

November 2, 2005

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

April 15, 2009

Patient safety rounds in a pediatric tertiary care center.

January 9, 2008

A systems approach to morbidity and mortality conference.

July 28, 2010

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.

January 25, 2006

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

June 16, 2021

Paying the piper: investing in infrastructure for patient safety.

June 4, 2008

Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations.

April 15, 2005

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital.

December 4, 2013

Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center.

February 20, 2008

Pediatric safety incidents from an intensive care reporting system.

May 27, 2009

Sustaining reliability on accountability measures at the Johns Hopkins Hospital.

January 27, 2016

Pediatric clinician comfort discussing diagnostic errors for improving patient safety: a survey.

April 22, 2020

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

May 6, 2009

Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology.

January 3, 2007

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Diagnostic Excellence in the ICU: Thinking Critically and Masterfully.

December 1, 2021

Patient Safety Innovations

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

April 7, 2022

Preventable harm occurring to critically ill children.

September 5, 2007

An estimate of missed pediatric sepsis in the emergency department.

June 2, 2021

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

January 20, 2010

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study.

March 16, 2016

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

March 15, 2006

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

Medication rounds: a tool to promote medication safety for children with medical complexity.

March 8, 2023

Nighttime and weekend medication error rates in an inpatient pediatric population.

December 15, 2010

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.

January 21, 2015

Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program.

November 23, 2005

Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program.

March 27, 2005

A model for the departmental quality management infrastructure within an academic health system.

September 28, 2016

Potential medication dosing errors in outpatient pediatrics.

January 11, 2006

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

June 7, 2006

The role of racism as a core patient safety issue.

February 5, 2020

Second victims and mindfulness: a systematic review.

August 21, 2019

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.

January 15, 2020

Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality.

August 3, 2022

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

Computer based medication error reporting: insights and implications.

June 21, 2006

Infection Control in the Intensive Care Unit.

August 25, 2010

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets.

February 3, 2021

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

August 10, 2011

Electronic fetal heart rate monitoring: applying principles of patient safety.

May 16, 2012

Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care.

April 28, 2021

Reducing the risk of adverse drug events in older adults.

April 17, 2013

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

March 9, 2022

Integrating patient safety into curriculum.

April 18, 2007

Using the ecological systems theory to understand black/white disparities in maternal morbidity and mortality in the United States.

August 26, 2020

Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis.

November 4, 2020

Patient safety and quality in the pediatric intensive care unit.

April 11, 2007

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events.

May 12, 2021

Medication reconciliation in a rural trauma population.

December 3, 2008

Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013.

July 22, 2015

The top patient safety strategies that can be encouraged for adoption now.

March 13, 2013

Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity.

February 15, 2023

System errors in intrapartum electronic fetal monitoring: a case review.

November 16, 2005

A practical tool to learn from defects in patient care.

February 8, 2006

Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis.

March 6, 2013

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

November 4, 2020

Electronic approaches to making sense of the text in the adverse event reporting system.

September 7, 2016

Advancing the science of patient safety.

May 25, 2011

Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.

September 18, 2019

Matt's story: learning from heartbreak.

May 9, 2018

Multi-level strategies to achieve resilience for an organisation operating at capacity: a case study at a trauma centre.

May 30, 2007

A look into the nature and causes of human errors in the intensive care unit.

March 27, 2005

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

June 16, 2010

Psychological safety and error reporting within Veterans Health Administration hospitals.

March 4, 2015

Detecting patient deterioration using artificial intelligence in a rapid response system.

March 25, 2020

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study.

November 24, 2021

"Teach-back" from a patient's perspective.

March 2, 2016

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting.

May 15, 2013

Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.

February 17, 2016

Adverse drug events in general practice patients in Australia.

April 19, 2006

Related Resources

Error disclosure in neonatal intensive care: a multicentre, prospective, observational study.

May 10, 2023

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks.

November 2, 2022

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

March 23, 2022

Evaluation of a second victim peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical specialties using the second victim experience and support tool (SVEST).

November 3, 2021

Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database.

October 14, 2020

Identifying medication errors in neonatal intensive care units: a two-center study

December 4, 2019

Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations.

February 27, 2019

Sustained improvement in neonatal intensive care unit safety attitudes after teamwork training.

September 12, 2018

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit.

August 8, 2018

Safety II behavior in a pediatric intensive care unit.

August 1, 2018

The emotional impact of errors or adverse events on healthcare providers in the NICU: the protective role of coworker support.

April 25, 2018

Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.

February 21, 2018

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning.

December 20, 2017

Alterations in Spanish language interpretation during pediatric critical care family meetings.

December 6, 2017

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study.

May 24, 2017

Rudeness and medical team performance.

April 12, 2017

Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.

March 15, 2017

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

November 30, 2016

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

November 30, 2016

Safe implementation of standard concentration infusions in paediatric intensive care.

August 24, 2016

Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.

August 3, 2016

The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.

November 25, 2015

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

November 11, 2015

Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.

November 4, 2015

Analysis of medication prescribing errors in critically ill children.

October 21, 2015

Higher quality of care and patient safety associated with better NICU work environments.

September 2, 2015

Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures.

September 2, 2015

See More About The Topic

Intensive Care Units

Facility and Group Administrators

Critical Care

Neonatology and Intensive Care

Epidemiology of Errors and Adverse Events

Transforming the morbidity and mortality conference to promote safety and quality in a PICU.

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Transforming the morbidity and mortality conference to promote safety and quality in a PICU.

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site