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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).


   Abstract
Top
 Abstract
Literature Review
 Purpose
 Methods
 Results
 Discussion
 Conclusions
 References
 
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.

Since the publication of the Institute of Medicine’s ground-breaking report, To Err is Human, Building a Safer Health Care System in 1999, patient safety has become an economic and political objective in Western countries.1–4 Reviews of hospital charts from the 1990s to 2009 have revealed that adverse events, defined as unintended injuries or complications that are provoked by medical management rather than the patient’s underlying disease, occurred in 2.9% to 16.6% of hospitalized patients.5–9 Moreover, in those retrospective studies, 20% to 57% of the adverse events were judged potentially preventable.5,9–11 However, agreement between chart reviewers in assessing preventability or contribution of care management to adverse events has remained poor, and preventable adverse events were more common in elderly and severely ill patients, suggesting that both preventable adverse events and in-hospital deaths are not systematically associated with medical errors.3,5,8,10–13 Indeed, 90% of preventable deaths seem to result from failures in the system of care organization or procedures, but not from caregivers’ negligence.1


   Literature Review
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 Abstract
 Literature Review
Purpose
 Methods
 Results
 Discussion
 Conclusions
 References
 
Errors and adverse events occur more frequently and their consequences are more serious in intensive care units (ICUs) than in many other settings for various reasons: ICU patients have multiple severe organ failures that involve greater complexity in emergency decision management and require invasive methods for treatment and/or monitoring.14–19 Nevertheless, data on the rates of adverse events and medical errors in ICUs are contradictory because nosocomial infections and iatrogenic complications due to invasive procedures or medications are not always preventable.14,17,18 In addition, adverse events are often responsible for patients’ being transferred to the ICU, further complicating the analysis of preventability of accidental injuries in ICUs.19 Therefore, the rates of preventable adverse events per 1000 ICU patient-days are estimated to be between 13 and 40, and in-ICU medical errors could prolong the ICU stay by 15% and increase hospital costs by 10%.14,17,19


Adverse events occur in up to 16% of hospitalized patients, and 57% of these events are preventable.

 

To confront this important health care problem, high-risk specialties, like surgery or anesthesiology, have successfully improved the quality of care they provide and the safety of their patients by systematizing morbidity and mortality conferences (MMCs).4,20 Indeed, MMCs for care providers are a traditional means of improving local care management through the discussion of adverse events, complications, or medical errors and the conception of alternative approaches to medical decision making.21,22 However, an interdisciplinary approach may also emphasize how MMCs can be useful in addition to their educational value, with respect to debate of clinical management and alternative treatments.21


   Purpose
Top
 Abstract
 Literature Review
 Purpose
Methods
 Results
 Discussion
 Conclusions
 References
 
Even though MMCs are considered a tool for evaluating and improving medical skills and practices, they lack a precise format and goals specifically tailored to the ICU. The aims of this report are to share our experience in implementing regular MMCs conducted with a specific, interdisciplinary approach for ICU practice and to evaluate the contribution of those MMCs to improving the quality of care and safety of patients in the intensive care unit.


   Methods
Top
 Abstract
 Literature Review
 Purpose
 Methods
Results
 Discussion
 Conclusions
 References
 
Design and Sample
This prospective, observational study was conducted in an 18-bed medical ICU of a tertiary teaching hospital in France (European Hospital Georges Pompidou, Paris) from November 2005 to October 2006. All patients admitted to the ICU during that year and experiencing an adverse event or dying in the ICU were eligible for analysis. In accordance with French law, no authorization was needed from the local institutional review board because of the observational design, and the study was approved by the Commission Nationale de l’Informatique et des Libertés for use of computerized medical data with protection of patients’ confidentiality.

Definitions
An adverse event was defined as an unintentional injury or complication that resulted in disability/ incapacity at the time of ICU discharge, death, or prolonged hospitalization and that was caused by health care management rather than by the patient’s underlying disease.6,23–25 Error was defined as "the failure of a planned action to be completed as intended (ie, error of execution) or the use of a wrong plan to achieve an aim (ie, error of planning)."1 Severity of an adverse event was classified as fatal, life-threatening, or minor. A fatal event was a complication principally responsible for death. Life-threatening adverse events required intensive care procedures (mechanical ventilation, use of vasopressors, hemodialysis, central venous catheterization, cardiac pacing, tube thoracostomy) and/or surgery, and such events led to prolongation of hospitalization or resulted in persistent or major disability/incapacity.26,27 Adverse events were considered minor when only noninvasive management and routine monitoring were required.26

An iatrogenic event was caused by drugs or by medical and/or surgical acts performed in accordance with standards of care during a patient’s ICU stay.28 Infections were considered nosocomial if they first appeared 48 hours or more after hospital admission or within 30 days after previous discharge. An event was considered preventable when the MMC discussion led to the consensus conclusions that it could have been avoided because it was the consequence of acts or prescriptions made without respecting state-of-the-art medical and nursing standards of practice or that it was caused by equipment failure.28,29 Preventability was assessed as an "error in management due to failure to follow accepted practice at an individual or system level." Accepted practice was taken to be "the current level of expected performance for the average practitioner or system that manages the condition in question."30

MMC Procedure
Before we implemented regular MMCs in our ICU, an informal meeting was held with the medical and nursing staff to present the goals and structures of this method and to clarify the introspective aspect of the MMC: we wanted an open peer discussion among physicians and nurses to review individual and team interventions and practices without intimidation, shame, or guilt. These rules were formally stated in a charter signed by the head of department and the MMC coordinators. A permanent group of coordinators, including a head nurse, a nurse, and a staff physician (the MMC moderator) was established and was always present at every MMC.

We developed a model based on explicit goals, which guided our discussions, supervised by the moderator and an external auditor (usually a physician but not necessarily an intensivist). Indeed, the participation of an outside auditor experienced in chairing such discussions could provide a more objective perspective than caregivers directly responsible for the patient and could contribute to improving the quality and usefulness of MMCs. The MMC procedure comprised 7 steps: case identification, case preparation and review, case analysis, case discussion, case classification, recommendations, and closure/ follow-up (Figure 1Go). MMCs were held monthly.


Figure 1
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  		Figure 1 Procedure for morbidity and mortality conferences used during the study.

 
  Case Identification.   The events retained for analysis were deaths (mortality analysis) and the following adverse events (morbidity analysis): unexpected cardiac arrest during ICU stay; unplanned extubation, defined as the deliberate removal of an endotracheal tube by the patient himself or accidental removal of an endotracheal tube during nursing care or patient transport31; need for reintubation within 24 to 48 hours after planned extubation during a procedure of weaning from mechanical ventilation32; and readmission to an ICU within 48 hours after ICU discharge. This list was voluntarily restrictive to facilitate exhaustiveness of data collection. The 4 adverse events retained for MMCs were consensually chosen during the preliminary informal meeting because they were considered potentially preventable in optimal ICU practice (possible markers of dysfunction). Adverse events were systematically collected by nurses and physicians in an "incident book" to which caregivers always had access. When an adverse event occurred, nurses or physicians noted the date and time of the incident, provided a factual description of what happened, and reported any suspected equipment failure. Systematic phone follow-up was done 48 hours after ICU discharge to ensure that the patient had not been transferred to another ICU.


We wanted an open peer discussion among physicians and nurses, without intimidation, shame, or guilt.

 

  Case Preparation and Review.   Residents and nurses who had treated the patients prepared the cases to be presented on the basis of the following criteria: educational value, possibility for improvement of quality of care, preventable outcome, and medical or nursing management critique. To enhance the overall learning experience, these staff members also completed the patient’s history, chronology of the facts, consequences of the adverse event, and personal, contextual, and organizational aspects that might have contributed to the event. They also knew that they could count on guidance from senior staff throughout the exercise. When necessary, a short literature review on specific subjects also was presented.

  Case Analysis.   The conference was conducted in a nonjudgmental and nonpunitive manner, but constructive input was sought from all participants regardless of their hierarchical status in our ICU, as had been stated in the formal charter placed in the incident book and approved by MMC coordinators and the head of the department. The moderator summarized the case, and then the presenting staff member or members identified and developed the specific topics for discussion. When appropriate, local performance was compared with external "benchmarks" by using data from published studies. The moderator and/or senior staff members were encouraged to report similar or relevant errors they had made and any lessons or benefits that they had drawn from reflecting upon those errors.

  Case Discussion.   The case was then opened for discussion with the participants. MMC attendees (staff physicians, nurses, and external auditor) focused the discussion on the severity, causality, and preventability of the event. The aim was to examine the system of care and medical management and to find ways to prevent the recurrence of the event.

  Case Classification.   An anonymous preprinted analysis grid (Table 1Go) served as a guideline to structure the case analysis and discussion and to keep the reflection focused on establishing severity, causality, and preventability of the event. Event severity and preventability were classified by using a 4- to 5-point Likert scale, according to Fleischer’s scale.33 Causality was classified according to preestablished items (Table 1Go) and discussion to consensus determined the hierarchy (primary or secondary) of factors when several had contributed to an event. Primary cause was considered the main causal factor contributing to an event.


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  		Table 1 Preprinted analysis grid used to classify severity, cause, and preventability of deaths and adverse events

 
  Recommendations and Follow-Up.   The moderator and external auditor closed the discussion by developing a case summary from the analysis grid. Finally, all participants were encouraged to help devise recommendations to prevent the recurrence of a similar event. Each consensually accepted action of prevention was subjected to follow-up by a designated staff member or working group with an implementation schedule included in a drafted protocol.

Data Collection
Baseline demographic data at the time of ICU admission included the patient’s age, sex, Simplified Acute Physiology Score (SAPS) II,34 score on the Acute Physiology and Chronic Health Evaluation (APACHE) II,35 and the organ dysfunctions and/or infection (ODIN) score.36 Comorbidity was estimated by using the McCabe and Jackson classification: class 0 for no underlying disease, class 1 for nonfatal underlying disease, class 2 for ultimately fatal disease (death expected within a 5-year period), and class 3 for rapidly fatal disease (death expected within 1 year).37 We also collected data on length of ICU stay and duration of invasive mechanical ventilation to assess exposure to the risk of in-ICU complications. We evaluated the frequency of adverse events by 4-hour intervals because nursing shifts in our ICU last 12 hours and regular supervision of patients by nurses was based on a minimum of 4-hour periods.

Data Analysis
Results are presented as number (%), mean (standard deviation), or median (range) for data that are not normally distributed. The nonparametric Mann-Whitney test was applied for comparison of relevant variables. The Fisher exact test was used to assess for significant differences between percentages. Analyses were conducted with Staview software (version 4.5, Abacus Concept Inc, Berkeley, California). A difference was considered significant when the {alpha} risk was less than 5% (P < .05).


   Results
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 Abstract
 Literature Review
 Purpose
 Methods
 Results
Discussion
 Conclusions
 References
 
During the study period, 646 patients were admitted to our ICU and 360 events involving 300 patients (46.4%) were analyzed in MMCs: 260 ICU deaths and 100 adverse events. Characteristics and demographic data of the patients discussed in the MMCs are summarized in Table 2Go.


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  		Table 2 Characteristics of the 300 patients whose events were included for analysis in morbidity and mortality conferences

 
Adverse Events
One hundred adverse events (17 unexpected cardiac arrests, 41 unplanned extubations, 39 reintubations, and 3 ICU readmissions) occurred in 72 patients. A total of 6008 ICU patient-days were surveyed, yielding a rate of 16.6 adverse events per 1000 ICU patient-days. Adverse events occurred more often (P = .001) between noon and 4 PM than at any other time (Figure 2Go). Seventy major adverse events occurred in 56 patients, and 27 patients had 30 minor adverse events (11 patients experienced both major and minor adverse events) during their ICU stays. Major adverse events occurred in older patients with longer ICU stays and prolonged durations of invasive respiratory support, whereas comorbidity and disease severity at ICU admission did not influence the severity of ICU-related adverse events (Table 3Go).


Figure 2
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  		Figure 2 Time distribution of adverse events (n=100; as defined in Figure 1Go) during a typical workday, by 24-hour period.

 

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  		Table 3 Relationships between characteristics of the 72 patients and primary cause of their 100 adverse events occurring in the intensive care unit and severity of the adverse events

 

Local performance was compared with external "benchmarks" by using data from published studies.

 

Deaths
Patients who died in the ICU (151 men and 109 women) were older (mean, 69 years; SD, 15 years) and were more severely ill at ICU admission (SAPS II: mean, 79; SD, 25; APACHE II score: mean, 34; SD, 10; ODIN score: median, 4; range, 0–7) than were survivors (age: mean, 58 years; SD, 17 years; SAPS II: mean, 60; SD, 21; APACHE II score: mean, 27; SD, 10; ODIN score: median, 3; range, 1–5; all P < .05). The median scores on the McCabe and Jackson classification were the same (median, 1; range, 0–3) for the patients who died and the survivors. Compared with survivors, patients who died had a shorter stay in the ICU (median, 3 [range, 1–9] days for patients who died vs median, 14 [range, 1–380] days for survivors; P < .001) and a shorter duration of mechanical ventilation (median, 3 [range, 1–55] for patients who died vs median, 9 [range, 1–312] days for survivors; P < .001).

Causality of Adverse Events and Deaths in the ICU
Participants in the MMCs classified 100 primary and 37 secondary causes of adverse events and 260 primary and 38 secondary causes of in-ICU deaths (Figure 3Go). Underlying disease was identified as the predominant primary cause of the events, especially in-ICU deaths. Secondary causes were attributed to iatrogenesis and nosocomial infections, human errors, unit management dysfunctions, and failures of coordination between departments. The distribution of the primary causes differed significantly (P < .001) between adverse events and in-ICU deaths (Figure 3Go). Conversely, the secondary causes of adverse events and in-ICU deaths had similar distributions (P = .77 for adverse events vs in-ICU deaths; Figure 3Go). Moreover, identified primary causes of major and minor adverse events did not differ significantly, but the origin of minor adverse events more often failed to be pinpointed in MMCs (Table 3Go). Unidentified causes mainly involved unplanned extubations.


Figure 3
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  		Figure 3 Distribution of primary and secondary causes classified by morbidity and mortality conferences for (A) 100 adverse events (for definition, see Figure 1Go) and (B) 260 deaths that occurred in the intensive care unit during the study period.

 
Preventability of Adverse Events and Deaths in the ICU
Among analyzed events, MMC participants agreed that 6.1% of in-ICU deaths and 36% of adverse events were preventable or probably preventable (Table 4Go). More severe illness at ICU admission and shorter ICU stay were associated with nonpreventable in-ICU deaths (Table 5Go). Conversely, nonpreventable adverse events were associated with older age and longer ICU stay but not with disease severity at ICU admission (Table 5Go). Moreover, comorbidity assessed with the McCabe and Jackson classification was not associated with preventability of adverse events and in-ICU deaths (Table 5Go). Preventable ICU deaths were associated with iatrogenesis, human errors, lacking unit management factors (failure to provide or enforce policy/protocol, poor task prioritization), and communication/ coordination failures between our ICU and other departments (Table 5Go). Underlying disease was associated with nonpreventable in-ICU deaths and adverse events (Table 5Go).


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  		Table 4 Preventability of deaths and adverse events that occurred in 300 intensive care patients

 

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  		Table 5 Relationships between characteristics of the 300 patients and primary cause of their death or adverse event in the intensive care unit and event preventability

 
Recommendations
Three major recommendations for system improvements were formulated by MMC participants: (1) rewrite a standardized procedure for the management of sepsis in neutropenic patients, especially the timing of administration of antibiotics; (2) standardize the daily prescription of mechanical ventilation settings by specifying the type of respirator used; and (3) redefine the task of each nurse during the management of cardiac and/or respiratory arrests. These recommendations were rapidly implemented, and no similar incidents have recurred since that time.

MMC Experience of Our ICU Team
We informally appraised the perspectives of nurses and physicians toward the MMC. This approach revealed different viewpoints. Introduction of MMCs stimulated nurses to discuss their organizational and individual problems more often and without fear. Physicians perceived the educational approach of MMC positively, particularly when senior staff selectively related similar or relevant errors they had made and the lessons or benefits they had drawn from them. The opinion of residents revealed that they feared judgment and that this fear persisted; absenteeism was not rare, especially among senior staff. Younger physicians expressed feeling liberated of hierarchical restraints and, as a result, expressed themselves more freely than during daily staff meetings. Nurses and physicians considered MMCs excessively time-consuming and, subsequently, MMC coordinators planned a screening session before each MMC to screen cases more selectively for value in education and/or quality improvement.


   Discussion
Top
 Abstract
 Literature Review
 Purpose
 Methods
 Results
 Discussion
Conclusions
 References
 
In this report we described our 1-year experience with implementing regular MMCs in an ICU. Results suggest that MMCs are a good tool for assessing quality of care and risks in ICU practice and for improving interpersonal and team communication. MMCs also should be considered useful means for improving safety of patients in the ICU. Our results also highlight the complex relationships among severity, causality, and preventability of unintended complications occurring in severely ill ICU patients.

Incidence Rates and Factors Associated With Severity of Adverse Events
Our data showed that adverse events in the ICU were more severe in older patients with longer exposure to the risk of life-threatening complications, as suggested by their prolonged invasive respiratory support and ICU stays, but comorbidity and disease severity at ICU admission did not seem to be related to the severity of adverse events. Moreover, we found a relatively low rate of adverse events, close to 17 per 1000 ICU patient-days. Our observations confirm the contribution of age and prolonged ICU stay to the occurrence of severe adverse events in the ICU.

Our results diverge, at least in part, from results of earlier prospective studies16,19,31,38 that indicated that higher rates of adverse events are associated with increased disease severity at admission. However, the differences in disease severity at ICU admission and the different methods chosen for identifying adverse events might explain these conflicting results. Indeed, our patients were initially in extremely critical condition, as indicated by the relatively high numbers of cardiac arrests and strokes at ICU admission, and we intentionally restricted our prospective identification to 4 adverse events corresponding, in our pragmatic approach, to possible markers of ICU dysfunction. In addition, exhaustive estimation of preventable adverse events does not seem to be the best indicator for assessing the safety of a health care system,39–41 and our findings suggest that selection of some clinically relevant adverse events for MMC analysis could be a realistic approach to assess safety of patients in ICUs.

Timing of Adverse Events
We found a peak from noon to 4 PM in the time distribution of adverse events during the study period, whereas previous exhaustive studies revealed a distribution with a daily morning peak in critical incidents.38,42 That observation led us to examine our care organization. The chronology of our adverse events could be explained by the increased workload generated by the medical decisions made after morning rounds or noon medical staff meetings and, consequently, could imply a preponderance of iatrogenic incidents, but in our study iatrogenesis accounted for only a relatively low percentage of adverse events. Another explanation was that fewer caregivers were available at bedside between noon and 2 PM because the doctor’s staff meeting coincided with the nurses’ lunch schedule, leading to a possible lapse in supervision of patients.


We focused on establishing severity, causality, and preventability of the event.

 

Although the team of doctors was smaller at night, fewer adverse events were reported at night, perhaps because meetings and breaks were diminished (nurses and doctors had food packs at their disposal to eat inside the ICU at night), and thus the density of caregivers present at bedside, remained more constant at night. In another study43 in a French ICU, admissions during off hours were not associated with higher mortality. Another explanation is that adverse events may occur when more physicians are present to initiate them.

Factors Associated With Causality and Preventability
The primary causes of adverse events and deaths in our study was the underlying disease, an uncontrollable factor that will more often lead to unpreventable deaths, signifying that patients may die of their disease in a way that is separate and apart from any adverse events. Pertinently, the distribution of secondary causes identified by MMC participants was similar for adverse events and in-ICU deaths; secondary causes included iatrogenesis, communication problems, and human errors, all of which could result in feeling guilt and shame during the MMC. The fact that underlying disease was classified as the main causal factor during MMCs could be interpreted as representing a bias on the part of the investigators resulting from a collective and unconscious mechanism of self-protection, also called defensive-passive culture.44 When they have been involved in the care of patients who died or experienced severe adverse events, nurses and doctors may have difficulty objectively discerning their personal contribution to cases presented during MMCs.


Adverse events occurred most frequently between noon and 4 pm.

 

Nonjudgmental and nonpunitive written rules for MMC procedure or the use of a more neutral convener could allay fears of retaliation or blame. We sought to mitigate this problem by engaging an external auditor with experience chairing such discussions, yet our findings illustrate some possible limitations of this safeguard and suggest that someone even more distant from the actual care should be used to rate the preventability and the causes of the adverse events.

Between 10% and 60% of unexpected complications that occur in the ICU could be prevented.14,16–19 We found that 36% of adverse events and 6.1% of in-ICU deaths were certainly or probably preventable, in agreement with previously published data. Our analysis also showed that the impact of disease severity at ICU admission on the preventability of events diverged between deaths and adverse events. This divergence was most probably because most of the prehospital cardiac arrest patients transferred to our care had enhanced disease severity scores at ICU admission and further shortened life expectancy in the ICU. Our observations also indicated that older age and longer exposure to the risk of complications influenced not only the severity of adverse events but also the frequency of unpreventable adverse events. As in earlier studies,1,10,16 we found that factors such as iatrogenesis, human errors, and communication problems were the main causes of preventable deaths. Surprisingly, we showed that primary cause, except for underlying disease, did not seem to affect the preventability of adverse events. However, the main limitation of analyzing the preventability of unexpected complications is intrinsic in the heterogeneity and imprecision of the definition of the preventable character of an event. Some studies highlighted the poor judgment reproducibility ({kappa} < .5) for assessing preventability of deaths and stressed that determination is dependent on a precise definition of preventability, file-analysis method, and rules of decision to judge the preventable character of death (majority or unanimity as in our MMC).5,8,11,17


Iatrogenesis, human errors, and communication problems were the main causes of preventable deaths.

 

Preparation of MMCs is time-consuming and requires motivation and perseverance from the local MMC coordinators. In this way, we consider the involvement of the head of the department crucial to achieve a cultural change within the ICU team by developing the concept of "useful error" during MMCs. Another potential limitation of our study is the extrapolation of the present results beyond our population of patients and method of analysis. However, we successfully shared our experience with other ICUs in our institution by organizing transverse case analyses, and our MMC procedure conforms with the methodological recommendations of the MMC group of the Société de Réanimation de Langue Française.


   Conclusions
Top
 Abstract
 Literature Review
 Purpose
 Methods
 Results
 Discussion
 Conclusions
References
 
Implementing regular MMCs into an ICU’s work schedule is both feasible and useful. In addition to its general educational value for the entire medical and nursing staff, especially residents, MMCs can be used to assess the quality of care, patient safety, and interpersonal, interdepartmental, and team communication. Our results suggest that organizing MMCs offers an excellent opportunity for open discussions among caregivers about epidemiological, organizational, and methodological aspects of their daily ICU practice.

FINANCIAL DISCLOSURES
None reported.

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   REFERENCES
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 Abstract
 Literature Review
 Purpose
 Methods
 Results
 Discussion
 Conclusions
 References
 

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