Transforming the Morbidity and Mortality Conference to Promote Safety and Quality in a PICU.
OBJECTIVE
Determine the effectiveness of a structured systems-oriented morbidity and mortality conference in improving the process of reviewing and responding to adverse events in a PICU.


METHODS
Prospective time series analysis before and after implementation of a systems-oriented morbidity and mortality conference.


METHODS
Single tertiary referral PICU in Baltimore, MD.


METHODS
Thirty-three patients discussed before and 31 patients after implementation of a systems-oriented morbidity and mortality conference over a total of 20 morbidity and mortality conferences, from April 2013 to March 2014.


METHODS
Systems-oriented morbidity and mortality conference incorporating elements of medical incident analysis.


RESULTS
There was a significant increase in meeting attendance (mean, 12 vs 31 attendees per morbidity and mortality conference; p < 0.001) after the systems-oriented morbidity and mortality conference was instituted. There was no significant difference in the mean number of cases suggested (4.2 vs 4.6) or discussed (3.3 vs 3.1) per morbidity and mortality conference. There was also no significant difference in the mean number of adverse events identified per morbidity and mortality conference (3.4 vs 4.3). However, there was an increase in the proportion of cases discussed using a standard case review tool, but this did not reach statistical significance (27% vs 45%; p = 0.231). Nevertheless, we observed a significant increase in the mean number of quality improvement interventions suggested (2.4 vs 5.6; p < 0.001) and implemented (1.7 vs 4.4; p < 0.001) per morbidity and mortality conference. All adverse event categories identified had corresponding interventions suggested after the systems-oriented morbidity and mortality conference was instituted compared with before (80% vs 100%). Intervention-to-adverse event ratios per category were also higher (mean, 0.6 vs 1.5).


CONCLUSIONS
A structured systems-oriented PICU morbidity and mortality conference incorporating elements of medical incident analysis improves the process of reviewing and responding to adverse events by significantly increasing quality improvement interventions suggested and implemented. Future work would involve testing locally adapted versions of the systems-oriented morbidity and mortality conference in multiple inpatient settings.
1Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA. 2Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 3Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
Christina L
CL
Cifra
Melania M
MM
Bembea
James C
JC
Fackler
Marlene R
MR
Miller
D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000458:organization & administration*; D065186:Interrupted Time Series Analysis; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration*; D013597:Systems Analysis