Activity: Morbidity/mortality meetings Practice evaluation - Measuring outcomes
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Category 1: Practice evaluation
Category 2: Knowledge & skills
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At times anaesthesia practice can take an emotional toll - please seek support if adverse events become personally stressful.External reports
External resources
Guideline Reference Document for Conducting effective Morbidity and Mortality Meetings for Improved Patient Care by
Morbidity and Mortality (M&M) meetings are a common and important component of surgical practice.(1-4) Although M&M meetings are something we all do, they are not necessarily something we always do well. In the absence of clear guidance, the Royal Australasian College of Surgeons (RACS) has received requests from its Fellows to help define the role and structure of M&M meetings. In response, RACS has developed this guideline reference document. In drafting the recommendations in this document, RACS understands that M&M meetings are conducted in different settings, with varying resources. As such, there is no one-size-fits-all approach.
Guidelines for Conducting and Reporting Morbidity and Mortality/Clinical Review Meetings by
This document follows on from the previous guidelines developed by the Clinical Excellence Commission (2016) (CEC) and provides a methodology for M&Ms using 6 core principles, guided by Human Factors and systems thinking to support comprehensive discussion from a diversity of clinical perspectives and generate system improvement opportunities. The guidelines support an evolution in clinical review processes away from linear cause-effect models centred on the individual most proximal to the adverse outcome, to more complex systems analyses that incorporate consideration of the organisational factors that both support and constrain individual practitioners.
Guidelines for Conducting Morbidity & Mortality Meetings by
This document describes a comprehensive list of functions for M&M review meetings, and individual departments will need to decide how to apply these most effectively in their circumstances.
Morbidity and Mortality Tool Kit for Low and Middle Income Countries by
Patient safety is a serious global public health concern. Studies have suggested that there is a 1 in 300 chance of a patient being harmed during health care. Once patients are harmed, Morbidity and Mortality (M & M) meetings are used to analyse cases with adverse outcomes and identify the underlying causes to bring about process changes, improve practices and patient safety. In many hospitals in lower- and middle-income countries (LMIC) this peer review mechanism does not yet exist, either due to unfamiliarity with the process or lack of human resources. In many of the smaller hospitals, only a single anaesthesia provider may cater to the surgical workload. In response, the World Federation of The Societies of Anaesthesiologists (WFSA) Safety and Quality of Practice Committee initiated the Mortality and Morbidity Toolkit project to develop a practical resource that includes the essential elements for anaesthesiologists to do analyse patient morbidity and mortality events and to improve their patient care. A toolkit is intended to guide frontline staff using a collection of authoritative and adaptable resources that can be implemented using practical approaches for addressing key issues. Toolkits provide a collection of open-source techniques and open access design, technical, and implementation resources that can help you plan and effectively implement M & M meetings in your hospital. The toolkit was developed after conducting an extensive needs-analysis survey in five LMICs and following a group consensus of the committee members. We have also included background reading materials to guide the readers on essential topics related to advancing patient safety and risk management. Each chapter provides a suggested reading list for deep reflection and further self-learning to support optimal care delivery.
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