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Nursing Morbidity and Mortality

The Clinical Nurse Specialist Role in Improving Patient Outcomes

Zavotsky, Kathleen Evanovich PhD, RN, CCRN, CEN, ACNS-BC; Ciccarelli, Melissa MS, RN-BC; Pontieri-Lewis, Vicky MS, RN, ACNS-BC, CWOCN; Royal, Sandia MS, RN, MSN, MPA, CCRN, CNRN; Russer, Elizabeth MS, RN, PCCN

doi: 10.1097/NUR.0000000000000205
Feature Article

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® 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.

Author Affiliations: Assistant Vice President, The Center for Professional Development, Innovation, and Research (Dr Zavotsky); Clinical Nurse Educator, Neuro/Orthopedics (Ms Ciccarelli); Clinical Nurse Specialist, Wound Ostomy and Continence (Ms Pontieri-Lewis); Clinical Nurse Educator, Surgical Critical Care (Ms Royal); and Clinical Nurse Educator, Respiratory Care/Behavioral Health (Ms Russer), Robert Wood Johnson University Hospital, New Brunswick, New Jersey.

The authors report no conflicts of interest.

Correspondence: Kathleen Evanovich Zavotsky, MS, RN, CCRN, CEN, ACNS-BC, The Center for Professional Development, Innovation, and Research, Robert Wood Johnson University Hospital, New Brunswick/Somerset Campuses, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08903 (

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