title: The experience of conducting Mortality and Morbidity reviews in a pediatric interventional radiology service: a retrospective study.
abstract: OBJECTIVE
  To review the experience and impact of conducting multidisciplinary Morbidity and Mortality (M&M) reviews in pediatric interventional radiology (IR) and describe issues, lessons, and recommendations.
  
  
  METHODS
  A dedicated functionality of an existing database was developed to retrospectively analyze pediatric IR M&M issues. Patient demographics, sedation/anesthesia, and procedure type were recorded. M&M issues were assigned to at least one of 10 categories and graded as major or minor per Society of Interventional Radiology (SIR) guidelines. Issues could result in recommendations, which were divided into six categories; each was classified as implemented or not implemented.
  
  
  RESULTS
  Of 31,983 patient encounters over a period of 10 years, 516 patient events (1.6%) were discussed at M&M reviews. A total of 772 categories were assigned; they related to the procedure (34%), patient comorbidity (20%), processes (15%), device (10%), management (8%), sedation/anesthesia (4%), medication (2%), ethical issues (1%), "near-misses" (1%), and other (5%). A total of 292 issues (57%) were graded as minor (SIR class A, n = 202; class B, n = 90) and 224 (43%) as major (SIR class C, n = 42; class D, n = 151; class E, n = 6; class F, n = 27). Twenty-seven deaths were reviewed. Of 397 recommendations made, 80% were fully implemented, 11% partially implemented, and 9% not implemented. Recommendations made related to process improvements (49%), technical changes (20%), interdisciplinary discussions (15%), educational endeavors (9%), contacting manufacturers (6%), and other issues (1%).
  
  
  CONCLUSIONS
  As a result of regular multidisciplinary M&M reviews being conducted, a large number of practical recommendations were made for improvements in quality of care, and implemented over a 10-year period. M&M reviews provide a useful forum for team discussions and are a vehicle for change and potential improvement in the delivery of care in a pediatric IR service.
authors.affiliation: Department of Medical Imaging, University of British Columbia, British Columbia, Canada.
authors.forename: Betty
authors.initials: B
authors.lastname: Tuong
authors.forename: Ziv
authors.initials: Z
authors.lastname: Shnitzer
authors.forename: Carolyne
authors.initials: C
authors.lastname: Pehora
authors.forename: Perry
authors.initials: P
authors.lastname: Choi
authors.forename: Mark
authors.initials: M
authors.lastname: Levine
authors.forename: Ganesh
authors.initials: G
authors.lastname: Krishnamurthy
authors.forename: Peter
authors.initials: P
authors.lastname: Chait
authors.forename: Michael
authors.initials: M
authors.lastname: Temple
authors.forename: Philip
authors.initials: P
authors.lastname: John
authors.forename: Joao
authors.initials: J
authors.lastname: Amaral
authors.forename: Bairbre
authors.initials: B
authors.lastname: Connolly
mesh_terms: D000293:Adolescent; D000758:Anesthesia / Q000009:adverse effects / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D054869:Clinical Audit; D015897:Comorbidity; D019992:Databases as Topic; D004358:Drug Therapy / Q000401:mortality; D064420:Drug-Related Side Effects and Adverse Reactions; D004868:Equipment Failure; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009864:Ontario; D010348:Patient Care Team / Q000706:statistics & numerical data; D010372:Pediatrics / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000145:classification / Q000401:mortality; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D011787:Quality of Health Care / Q000706:statistics & numerical data; D015641:Radiography, Interventional / Q000009:adverse effects / Q000401:mortality; D015642:Radiology, Interventional / Q000706:statistics & numerical data; D012189:Retrospective Studies; D055815:Young Adult