Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice.
BACKGROUND
Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units.


OBJECTIVE
To evaluate the feasibility and usefulness of regular morbidity and mortality conferences specific to intensive care units for improving quality of care and patient safety.


METHODS
For 1 year, a prospective study was conducted in an 18-bed intensive care unit. Events analyzed included deaths in the unit and 4 adverse events (unexpected cardiac arrest, unplanned extubation, reintubation within 24-48 hours after planned extubation, and readmission to the unit within 48 hours after discharge) considered potentially preventable in optimal intensive care practice. During conferences, events were collectively analyzed with the help of an external auditor to determine their severity, causality, and preventability.


RESULTS
During the study period, 260 deaths and 100 adverse events involving 300 patients were analyzed. The adverse events rate was 16.6 per 1000 patient-days. Adverse events occurred more often between noon and 4 pm (P = .001).The conference consensus was that 6.1% of deaths and 36% of adverse events were preventable. Preventable deaths were associated with iatrogenesis (P = .008), human errors (P < .001), and failure of unit management factors or communication (P = .003). Three major recommendations were made concerning standardization of care or prescription and organizational management, and no similar incidents have recurred.


CONCLUSIONS
In addition to their educational value, regular morbidity and mortality conferences formatted for intensive care units are useful for assessing quality of care and patient safety.
Ksouri
Hatem
H
Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, France.
Balanant
Per-Yann
PY
Tadié
Jean-Marc
JM
Heraud
Guillaume
G
Abboud
Imad
I
Lerolle
Nicolas
N
Novara
Ana
A
Fagon
Jean-Yves
JY
Faisy
Christophe
C
D000367:Age Factors; D000368:Aged; D002423:Cause of Death; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration* / Q000592:standards; D033183:Interdisciplinary Communication; D007396:Internship and Residency; D008297:Male; D019300:Medical Errors / Q000401:mortality* / Q000517:prevention & control*; D008875:Middle Aged; D009017:Morbidity; D009741:Nursing Staff, Hospital; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000379:methods*; D017751:Safety Management / Q000379:methods*; D013997:Time Factors