education, magnet(R), quality outcomes



  1. Zavotsky, Kathleen Evanovich PhD, RN, CCRN, CEN, ACNS-BC
  2. Ciccarelli, Melissa MS, RN-BC
  3. Pontieri-Lewis, Vicky MS, RN, ACNS-BC, CWOCN
  4. Royal, Sandia MS, RN, MSN, MPA, CCRN, CNRN
  5. Russer, Elizabeth MS, RN, PCCN


Purpose: The purpose of this article is to discuss the development and implementation of a nursing morbidity and mortality (M&M) monthly conference at an academic medical center. Nursing M&M was developed as a peer review process in which cases where clinical errors or misjudgments that have occurred are reviewed in a nonpunitive setting. The cases are selected based on the National Database for Nursing Quality Indicators and the implications they have for the quality of nursing practice.


Background/Rationale: Morbidity and mortality conferences are well documented in the physician arena as an avenue to review and discuss adverse events. There is little published in the literature related to nursing using this peer review format and what impact this forum can have on clinical outcomes. Clinical nurse specialists and clinical nurse educators are oftentimes positioned to help implement this type of forum and evaluate the impact that it has for the staff and patients that they work with.


Description: The clinical nurse specialists/clinical nurse educators at this fourth-time designated Magnet(R) academic medical center facilitate the monthly M&M and select 4 to 5 cases to present. At the end of each brief presentation, the outcome is determined to be either preventable or unpreventable. Action items for educational needs are also identified.


Outcomes: Nursing M&M has been well attended over the past year. Since its inception, multiple practice changes have been implemented. Based on the positive feedback from the evaluations, this monthly conference has become standing practice in the institution.