Morbidity and Mortality Meetings

Morbidity and Mortality Meetings

Setting the Scene

June 14th 2019David Storey


Morbidity and Mortality Meetings should serve three functions at Departmental level

CatharsisEducation

Patient Safety

Potential Outcomes for the forum:

1. Reach consensus about the purpose of M&M’s2. Inform about initiatives across NSW and Victoria3. Reach recommendations for the CEC State wide

reference group to develop• Update of the CEC M&M guidelines on the conduct of

M&M’s (including system based discussion)• Guidance for governance of M&M meetings and their

place within other Patient Safety processes• Guidance about the role of data in M&Ms

4. Guide potential Qualified Privilege legislation reform

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Morbidity and Mortality MeetingsM & M Meetings should

1. Be a safe space for learning2. Be a forum in which frank multidisciplinary

discussion is encouraged3. Include system based as well as linear analysis4. Have access to relevant, timely data.5. Adopt a robust process for dissemination of

lessons learned6. Have a locally agreed governance and role

within other Patient Safety processes.


This is not a true story, but it could be –

• 75 yr old obese woman presented to a A1 ED on 5th January 2017 with acute abdominal pain

• Past history of rheumatoid arthritis, now back onto prednisone 15mg / day

• Unconvincing physical examination, CT performed at 11pm, reported as normal



• The AMO (Dr Storey) accepts the patient

• Next morning the patient is critically unwell –CT is reviewed

• Late laparotomy for faecal peritonitis, long stormy recovery leading to dependence



The patient’s journey is presented at the Department’s M&M in February

• Criticism of the SRMO and the radiology reg on nights

• Anecdotes about the dangers of the acute abdomen in obese, elderly, immunosuppressed



The patient’s journey is presented at the Department’s M&M in February• No discussion about

• Handovers (including transmission of images)• Changes to calling criteria• Delay in surgery due to planned cases

• No IIMS report, no nurses present


Catharsis Dr Storey and others were able to reflect upon the sequence of events and to share their experience

EducationThe junior medical officers present learned about • The assessment of some groups of patients with

abdominal pain• The need to review CT scans themselves

Patient SafetyThe lessons were not shared with other clinicians, and the system failures were not addressed



Nine months later

• Dr Storey and the LHD receive a medicolegal claim

• The JMO’s M&M spreadsheets are demanded under subpoena



The court awards a total of $1.2 M. The judge criticizes many aspects, but especially• The failure of Dr Storey and the LHD to show

any evidence of efforts to prevent recurrence• The evidence from the JMO spreadsheets that

there had been four similar cases in 2 years



• Dr Storey retires from clinical practice and takes a position at the CEC as Clinical Advisor

• Nothing else changes.


Morbidity and Mortality Meetings can serve three functions at Departmental level

CatharsisEducation

Patient Safety

But they don’t currently do the first two well, and the third barely at all


The CEC’s role

1. Guidelines 2016

2. State wide reference group

Why a state-wide reference group?

• Opportunity to address the challenges identified in the development of robust M&M processes.

• Sharing local solutions and consideration for state-wide implementation

• Local Teams Developing Creative Solutions

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1. State wide M&M reference group

STATE WIDE REFERENCE GROUP MORTALITY AND MORBIDITY Jim Mackie, Harvey Lander, Karen Patterson, Debbie Draybi CEC

Angela Firth, Joanna Lemmich, Shannon Nott, Kelly Bradley, Maryanne Mitchell

WNSWLHD

Angela Sutherland NNSWLHDDave Gillespie, Shehnarz Selindra, Donna Dorrington, Kathleen RyanMNCLHDGeorge Rubin, Sarah-Jane Messum SESLHD

Leigh Haysom, Welkee Sim JH&FMHNMelissa O’Brien, Michella Stirrat HNELHD

Yasoda Sathiyaseelan NBMLHDMichael Piza NSW CI

Sharon Carey SLHD

Kimberley Flood FWLHD

George Douros Safer Care Vic

Aiden Foy HETI

Wilson Yeung, Moe Kermail eHealth

Local Teams Developing Creative Solutions• MNCLHD: Use of M&M SharePoint tool• SESLHD: M&M tool with system analysis

template• HNELHD: Experiences of QP and testing use of

QIDs for M&Ms• eHealth: Pascal metrics and IIMS system

development related to M&MS• Safer Care Victoria: M&M facilitation tool• JFMH: Challenges for starting a new M&M• WNSWLHD: Engagement in rural settings

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• What can we learn from the Victorian experience ?• What can a more systems based approach offer ? • Where does outcome data fit ?• Can we focus on learning rather than blaming ?• How can this work for isolated health services ?• Is legal protection needed ? If so, does the Act in

NSW need review ?

Documents

Morbidity and Mortality Meetings