Learning Together: A Team-Based Approach to Adverse Events in the Pediatric Intensive Care Unit

First Author: Kelly Collins, BSN, RN, CPN, CCRN
Co-Author: Wesley T. Green, BSN, RN, – Nurse Manager, Cincinnati Children's Hospital
Co-Author: Daniel Loeb, MD, MEd – Assistant Professor, Cincinnati Childrens Hospital Medical Center
Co-Author: Ken Tegtmeyer, MD, FAAP, FCCM – Cincinnati Children's Hospital Medical Center


Introduction: Morbidity & Mortality (M&M) conferences are key learning opportunities to improve patient care. In our pediatric intensive care unit (PICU), traditional M&M conferences primarily involve physician & nurse practitioner participation. To broaden this impact, a multidisciplinary team sought to extend key learnings to nurses & respiratory therapists.


Methods: A team comprised of a nursing leader, clinical nurse specialist, & pediatric intensivist developed a new conference series designed to engage bedside staff in case-based learning using cases presented at the larger M&M conference. These “Bedside M&M” sessions occur every other month & feature an educational overview followed by selected patient cases that reinforce or expand upon the education topic. After each session, attendees are invited to complete an anonymous, open-ended survey via Microsoft Forms. Responses to the survey are qualitatively analyzed to identify common themes & to guide the planning of further sessions.


Results: The first session of “Bedside M&M” was held in October 2024 with four subsequent sessions held to date. Each session has on average 45 attendees from a variety of clinical backgrounds including nursing, respiratory therapy & physicians. 84% of respondents identified as registered nurses with 49% indicating less than three years of PICU experience. All respondents noted that they would attend a future session, reporting both high satisfaction with the conference both quantitatively & qualitatively. Three common themes that emerged from survey analysis include:
1. Value of learning
2. Importance of multidisciplinary conversation
3. Desire for system level improvement


Conclusions: Engaging bedside staff in review & discussion of adverse events in the PICU creates a culture of shared learning & transparency. Multidisciplinary discussion of real cases appears to empower bedside staff to recognize potential care gaps, deepen their understanding of medical decision making, & reflect on their practice.