Performing a standardized chart review on cases discussed during M&M conferences can uncover additional safety events, but others are only discovered during the discussion.
BMJ Qual Saf. 2014 Jul 18; [Epub ahead of print].
The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit.
Cifra CL, Jones KL, Ascenzi J, et al. BMJ Qual Saf. 2014 Jul 18; [Epub ahead of print].
In this study, applying standardized chart reviews for incidents discussed during morbidity and mortality conferences in a pediatric intensive care unit uncovered many previously unrecognized safety events. Conversely, the conferences revealed near misses and diagnostic errors that were not obvious in chart documentation.
Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.
Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.
Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.
Chandonnet CJ, Kahlon PS, Rachh P, et al. Pediatrics. 2013;131:e1961-e1969.
Medical Event Data Collection and Analysis Service (MEDCAS).
Cognitive Technologies Laboratory, University of Chicago.
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Patient safety event reporting in critical care: a study of three intensive care units.
Harris CB, Krauss MJ, Coopersmith CM, et al. Crit Care Med. 2007;35:1068-1076.