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Cases & Commentaries
- Web M&M
Mary Caldwell, RN, PhD, MBA; Kathleen A. Dracup, RN, DNSc; September 2003
A patient given diltiazem rather than saline suffers severe bradycardia requiring temporary pacemaker.
Journal Article > Review
Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.
Smaggus A, Mrkobrada M, Marson A, Appleton A. BMJ Qual Saf. 2018:27:74-84.
This systematic review identified 19 studies about efforts to enhance morbidity and mortality conferences to support quality and safety improvement and education. Researchers found that strategies like integrating morbidity and mortality rounds into operational quality processes and standardizing elements of the presentation can enhance the value of morbidity and mortality conferences. They recommend further study into the educational outcomes of safety-focused morbidity and mortality rounds.
Journal Article > Commentary
Slomski A. JAMA. 2019;321:1239-1241.
Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.