This study analyzed the impact of implementing monthly multidisciplinary morbidity and mortality conferences (MMCs) in the intensive care unit (ICU). Using a standard format of case review, analysis, and discussion, the conferences reviewed in-ICU deaths and adverse events including unexpected cardiac arrest, unplanned extubation, reintubation within 24 to 48 hours after planned extubation, and readmission to the ICU within 48 hours after ICU discharge. During a 1 year period in an 18-bed ICU, 267 ICU deaths and 100 adverse events involving 300 patients were analyzed. After MMC review, 6.1% of deaths and 36% of adverse events were identified as being preventable based on consensus that the event could have been avoided. After recommendations that focused on standardizing care or prescription and organizational management were followed, no similar incidents were found to have occurred. The authors concluded that MMCs are a useful tool for...

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