(1103) Learning From the Past: Revamping Mortality and Morbidity Conference

Introduction: One in 20 patients are exposed to avoidable harm per a 2019 meta-analysis by Panagioti et al. Learning from these events is an important and required part of medical training, which is often accomplished through morbidity and mortality (M&M) conferences. These M&M conferences can create a psychologically unsafe environment, however, requiring thoughtful review of unanticipated outcomes. We assessed the need for an M&M conference within a Pediatric Intensive Care Unit (PICU) that currently has a review limited to mortalities that is not section wide.

Methods: To support a new M&M conference, pediatric critical care providers—including attendings, fellows, and advanced practice practitioners (APPs)—were surveyed in Summer 2024. The survey included questions about awareness of PICU deaths, and their experiences with unanticipated/poor patient outcomes.

Results: We had 31 responses from 15 attendings, 11 APPs, and 5 fellows. Nearly a quarter (7/31) felt unaware of PICU patient deaths. All providers (100%, 31/31) agreed that patient cases with unanticipated/poor outcomes should be reviewed, and that discussing other PICU member’s unanticipated/poor outcomes is valuable for learning. Almost all (87%, 27/31) agreed that discussing patient cases with unanticipated outcomes helped with their coping/wellness; all but one (97%, 30/31) agreed that discussing unanticipated outcomes aids in learning patient safety principles. Around half (15/31) disagreed that the section discusses ways to prevent recurring errors; only 29% (9/31) agreed that changes are implemented based on PICU event reports. Over three quarters (81%, 25/31) disagreed that there is a structured format to discuss PICU patient cases with unanticipated/poor outcomes, and 74% (23/31) disagreed that there currently is an open and safe environment to discuss PICU cases with unanticipated/poor outcomes.

Conclusions: Preliminary results from this survey suggest providers want a venue to discuss unanticipated/ poor patient outcomes but do not currently have one. Findings support the initiative to develop an M&M curriculum in a psychologically safe environment . We will continue to assess the impact of this M&M curriculum and adapt it as needed to meet the goals of identifying areas of improvement for better and safer patient care.