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American Journal of Critical Care. 2010;19: 135-145 doi:10.4037/ajcc2010590
Copyright © 2010 by the American Association of Critical-Care Nurses.
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CE Article

Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

By Hatem Ksouri, MD, Per-Yann Balanant, RN, Jean-Marc Tadié, MD, Guillaume Heraud, RN, Imad Abboud, MD, Nicolas Lerolle, MD, PhD, Ana Novara, MD, Jean-Yves Fagon, MD, PhD and Christophe Faisy, MD, PhD. All authors are from the Department of Medical Intensive Care, European Hospital Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris–Descartes, Paris, France.

Corresponding author: Christophe Faisy, MD, PhD, Department of Medical Intensive Care, European Hospital Georges Pompidou, 20 rue Leblanc, 75908 Paris, Cedex 15, France (e-mail: christophe.faisy{at}egp.aphp.fr).

Background Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units.

Objectives 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.

Conclusion 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.

Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Describe the differences between preventable and nonpreventable adverse events, and the challenges associated with determining if an event is preventable.
  2. Identify the necessary components of a process for analyzing adverse events to determine their severity, causality, and preventability.
  3. Discuss important considerations related to implementation of regular mortality and morbidity conferences and their potential benefits and/or limitations.
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.


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