title: [Mortality and morbidity conference: A tool for quality and safety of care continuous improvement].
abstract: OBJECTIVE
  The mortality and morbidity conference (MMC) is one of the keystones in the evaluation of quality of care. The objective of this work was to describe a MMC by presenting a case report.
  
  
  METHODS
  A 16-year old man suffering from chronic anaemia had to be transfused with two units of red blood cells in an outpatient unit. Although the transfusion went well for the first unit, the patient presented haemolysis during the transfusion of the second unit because the nurse administered the wrong unit. The incident was analysed during a mortality and morbidity conference with the attendance of the hemovigilance local correspondent. Immediate causes of the event were the failure to respect the transfusion procedure: in advance compatibility testing, failure to check the patient and blood component identification just before the transfusion. Factors contributing to the event were the deviation of transfusion practices, poor working conditions of nurses, linked to inadequate staff in relation to the activity. The discussion of the incident led to develop an action plan.
  
  
  CONCLUSIONS
  This case shows the interest for staff members to discuss an adverse event. However, a well-defined methodology for conducting mortality and morbidity conferences is lacking and leads to a wide heterogeneity between teams. Major differences refer to criteria for case selection and quality of participants. This heterogeneity is likely to have an impact of the efficacy of mortality and morbidity conferences regarding the quality and safety of care.
authors.affiliation: Unité d'évaluation médicale, pôle de santé publique, pavillon Taillefer, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France. pfrancois@chu-grenoble.fr
authors.forename: P
authors.initials: P
authors.lastname: François
authors.forename: E
authors.initials: E
authors.lastname: Sellier
authors.forename: P
authors.initials: P
authors.lastname: Pouzol
authors.forename: G
authors.initials: G
authors.lastname: Bal
authors.forename: J
authors.initials: J
authors.lastname: Labarère
mesh_terms: D000293:Adolescent; D000740:Anemia / Q000209:etiology / Q000628:therapy; D001787:Blood Group Incompatibility / Q000097:blood; D058731:Blood Safety; D016026:Bone Marrow Transplantation; D003226:Congresses as Topic / Q000458:organization & administration / Q000639:trends; D017707:Erythrocyte Transfusion / Q000009:adverse effects* / Q000451:nursing; D006461:Hemolysis; D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000009:adverse effects / Q000517:prevention & control*; D010355:Patient Identification Systems; D011183:Postoperative Complications / Q000097:blood / Q000209:etiology / Q000628:therapy; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000150:complications / Q000601:surgery; D058996:Quality Improvement / Q000458:organization & administration*; D012308:Risk Management / Q000458:organization & administration*; D017751:Safety Management / Q000458:organization & administration*