title: The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit.
abstract: OBJECTIVE
  To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics.
  
  
  METHODS
  Retrospective record review.
  
  
  METHODS
  Single tertiary referral PICU in Baltimore, Maryland, USA.
  
  
  METHODS
  96 patients discussed at the PICU MMC over 14 months (November 2011-December 2012).
  
  
  METHODS
  Safety events and their characteristics (medical error category, severity and preventability).
  
  
  RESULTS
  A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses.
  
  
  CONCLUSIONS
  Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.
authors.affiliation: Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.
authors.forename: Christina L
authors.initials: CL
authors.lastname: Cifra
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Kareen L
authors.initials: KL
authors.lastname: Jones
authors.affiliation: Pediatric Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Judith
authors.initials: J
authors.lastname: Ascenzi
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Utpal S
authors.initials: US
authors.lastname: Bhalala
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Melania M
authors.initials: MM
authors.lastname: Bembea
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Fackler
authors.affiliation: Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Marlene R
authors.initials: MR
authors.lastname: Miller
mesh_terms: D000293:Adolescent; D015142:Baltimore; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D019300:Medical Errors / Q000145:classification / Q000401:mortality / Q000517:prevention & control / Q000706:statistics & numerical data*; D009017:Morbidity; D061214:Patient Safety; D012189:Retrospective Studies; D017751:Safety Management; D012720:Severity of Illness Index; D055815:Young Adult
keywords: Adverse events, epidemiology and detection; Critical care; Medical error, measurement/epidemiology; Morbidity and mortality rounds; Paediatrics