Library resource guides: ANZCA & FPM CPD Program resources: Morbidity/mortality meetings

Guide index

Morbidity/mortality meetings

Interactive discussion with a group of clinicians with those involved in individual cases present. Includes review of management to understand factors (including those related to systems) contributing to mortality or morbidity.

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These meetings may be organised by a department, private practice group, group of colleagues with similar scopes of practice, or run as part of a conference program.
Presentations must conform to relevant regulations on discussing patient details (which may require de-identification).

Participate in a departmental morbidity & mortality (M&M) meeting - for example: ICU M&M meeting
Participate in a private practice morbidity & mortality (M&M) meeting
Participate in an anaesthetic group morbidity & mortality (M&M) meeting - for example: Northern Anaesthetists M&M meeting

CPD Value: CPD participants may claim this under the Practice evaluation - measuring performance morbidity/mortality meetings activity.

At times anaesthesia practice can take an emotional toll - please seek support if adverse events become personally stressful.

External reports

External resources links

NSW Government Clinical Excellence Commission. Morbidity and Mortality meetings
Morbidity and Mortality meetings (M&Ms) or clinical review meetings allow departments/ specialties/ facilities to review the quality of the care that is being provided to their patients.
RCS: Morbidity and Mortality Meetings
The College’ s guidance is a practical guide for setting up, running and participating in high quality surgical M&M meetings.
How to host a Mortality and Morbidity meeting without making anyone cry, Don't Forget the Bubbles, 2022. Available at: https://doi.org/10.31440/DFTB.47134
Here are six steps to facilitating a useful, interesting and (dare I say) enjoyable M&M.
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Written on 27/01/2022, Last updated 19/08/2023

Guideline Reference Document for Conducting effective Morbidity and Mortality Meetings for Improved Patient Care by Royal Australasian College of Surgeons Research, Audit and Academic Surgery 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.
Publication Date: 12 April 2017
Guidelines for Conducting and Reporting Morbidity and Mortality/Clinical Review Meetings by Clinical Excellence Commission 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.
ISBN: 9781760814175
Publication Date: 2020
Guidelines for Conducting Morbidity & Mortality Meetings by St Vincents Health Australia 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 World Federation of The Societies of Anaesthesiologists (WFSA) Safety and Quality of Practice Committee 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.
Publication Date: January 1, 2023

Title: Guiding principles for effective Morbidity and Mortality (M&Ms)
This webinar provides an overview of the M&M guidelines with a focus on the What, Why and How to support the evolution of M&Ms as the cornerstone of safe and reliable care. This includes a demonstration of the new M&M module recently developed in the CEC Quality Improvement Data System (QIDS) platform.
Duration: 65 mins approx.

webAIRS

WebAIRS

webAIRS
webAIRS stands for web-based Anaesthetic Incident Reporting System. It's an online reporting tool available to all anaesthetic departments in Australia and New Zealand. The system was developed by the Australian and New Zealand Tripartite Anaesthetic Data Committee (ANZTADC).

Incidents
News
Events
Publications
FAQ

WebAIRS articles
Full-text access to WebAIRS-related articles.

ANZCA: Anaesthetic incident reporting
We oversee a range of incident reporting activities in Australia and New Zealand, including mortality reporting and webAIRS, to ensure that we continue to be two of the safest countries in the world to undergo anaesthesia.

ANZCA & FPM resources

ANZCA & FPM resources links

CPD Activity Guide
This guide contains a list of all the activities associated with the ANZCA and FPM CPD Program, as well as links to associated individual activity guides and forms.

ANZCA: Safety & Quality Resources Library Guide
This guide contains resources and information to complement those on the ANZCA Safety & Advocacy website. It includes a list of relevant college professional documents (policies, position statements, guidelines).
ANZCA: Wellbeing Library Guide
ANZCA Library has compiled a list of support resources relevant to the general wellbeing of medical practitioners.
ANZCA: Safety & Advocacy Hub
This hub brings together resources related to safety, standards of practice - including anaesthetic incident reporting (webAIRS), critical incident debriefing, advocacy, and indigenous and global health, including those resources available through the ANZCA library.

ANZCA: College Publications
Our publications keep members up-to-date and lift the profile of anaesthesia and pain medicine with policy makers and in the wider community. Includes ANZCA Bulletin, the Blue Book, APM: SE, Safety of Anaesthesia Reports, Standards for Anaesthesia and Perioperative Care.

Library resources

Library resources links

BMJ Quality & Safety
Online: Vol. 1, 1992 - current
>> Alternate/direct access via BMJ Journals.
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BMJ Quality & Safety provides a rich mix of news, opinion, debate and research for academics, clinicians, healthcare managers and policy makers. It encourages the science of improvement, debate, and new thinking on improving the quality of healthcare. The journal is led by a patient-focused editorial team with a view towards helping all team members improve their knowledge with the overall goal of improving patient care. The journal integrates the academic and clinical aspects of quality and safety in healthcare by encouraging academics to create evidence and knowledge valued by clinicians and clinicians to value using evidence and knowledge to improve quality.
BMJ Open Quality
Online: Vol. 6, 2017 - current
>> Alternate/direct access via BMJ Journals.
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BMJ Open Quality is dedicated to publishing high quality, peer reviewed healthcare improvement work. Articles covering original research, local, national and international QI projects, value-based healthcare improvement initiatives and educational improvement work are all considered.

BMJ Open Quality uses continuous publication online, to ensure timely, up-to-date knowledge is available worldwide. The journal adheres to a rigorous and transparent peer review process and papers are considered on the basis of methodological soundness rather than priority or novelty.
Joint Commission Journal on Quality and Patient Safety
Online: Vol. 37, 2011 - current
>> Alternate/direct access via ClinicalKey.
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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care.

Higginson J, Walters R, Fulop N. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf. 2012 Jul;21(7):576-85.
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Abstract
Introduction: National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety.

Methods: To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members.

Findings: The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospital's governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance.

Conclusion: M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.
Steel EJ, et al. Systematic Review of Morbidity and Mortality Meeting Standardization: Does It Lead to Improved Professional Development, System Improvements, Clinician Engagement, and Enhanced Patient Safety Culture? J Patient Saf. 2024;20(2):125-130.
Note: Restricted content is accessible via the secure ANZCA E-Reserves module.
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Abstract
Objectives: This systematic review sought to better understand the effect of standardized Morbidity and Mortality meetings (M&Ms) on learning, system improvement, clinician engagement, and patient safety culture.

Methods: Three electronic databases were searched using a range of text words, synonyms, and subject headings to identify the major concepts of M&M meetings. Articles published between October 2012 (the end date of an earlier review) and February 2021 were assessed against the inclusion criteria, and thematic synthesis was conducted on the included studies.

Results: After abstract and full-text review in Covidence, from 824 studies identified, 16 met the eligibility criteria. Studies were mostly surveys (n = 13) and evaluated effectiveness primarily from the perspectives of M&M chairs and participants, rather than assessment of objective improvement in patient outcomes. The most prevalent themes relating to the standardization of M&M processes were case selection (n = 15) and administration (n = 12). The objectives of quality improvement and education were equally prevalent (12 studies each), but several studies reported that these 2 objectives as conflicting rather than complementary. Clinician engagement, patient safety culture, and organizational governance and leadership were identified as facilitators of effective M&Ms.

Conclusions: There is insufficient evidence to guide best practice in M&Ms, but standardized structures and processes implemented with organizational leadership and administrative support are associated with M&Ms that address objectives related to learning and system improvement. Standardization of the structures and processes of M&Ms is perceived differently depending on participants' role and discipline, and clinician engagement is critical to support a culture of safety and quality improvement.

ANZCA & FPM CPD Program resources: Morbidity/mortality meetings

Morbidity/mortality meetings

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WebAIRS

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