Policy and Procedure Title: Mortality and Morbidity Review

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Mortality and Morbidity Review

Policy and Procedure Title: Mortality and Morbidity Review (M&MR)

Ownership:

Hospitals

Department

Effective Date: Code:

Revision Due Date: Type of Policy and procedure:

Administrative

Technical (Clinical) Done By: Hospitals Department

Applies to: All MOHAP Healthcare facilities

1. Purpose & Scope:

1.1 The purpose of M&MR varies, however the most common goals are: medical management,

teaching, patient safety and quality improvement.

1.2 An effective M&MR should: identify events resulting in adverse patient outcomes; foster

discussion of those events; identify and disseminate information and insights about patient care

that are drawn from experience; reinforce accountability for providing high-quality care, and create

a forum in which physicians acknowledge and address reasons for mistakes.

1.3 This policy applies to all hospitals in the MOHAP.

2. Policy Statement:

2.1 Hospitals M&MR reviews are conducted by the M&MR committee in each hospital.

2.2 The members of the Hospital Mortality and Morbidity Review (HM&MR) committee shall be

appointed by the hospital Director

2.3 It’s a multidisciplinary team; Participants include the providers involved in the care of the patient,

selected experts, and others who can contribute to the analysis of the event and to the development

of practical recommendations to improve patient safety.

2.4 Managing Conflict Of Interest:

2.4.1 HM&MR functions shall be carried in good faith, honestly and impartially and situations that

might compromise the integrity of these functions or lead to conflicts of interest should be

avoided.

2.4.2 When members of the committee believe they have a conflict of interest on a subject that will

prevent them from reaching an impartial decision or undertaking an activity consistent with

the Committee’s functions, they must declare the conflict of interest and withdraw

themselves from the discussion and/or activity.

2.4.3 Members of the committee shall attend meetings and undertake committee activities as

independent persons responsible to the committee as a whole. HM&MR Committee should

not, therefore, assume that a particular group's interests have been taken into account because

a member is associated with a particular group.

2.5 Confidentiality:

2.5.1 The statutory requirements from the HM&MR committee should be noted, which prevent

disclosure of information related to reviewed cases (refer to the document of “Professional

conduct and ethics principles for a general occupation” produced by the Federal Authority for

Government Human Resources, www.fahr.gov.ae).

http://www.fahr.gov.ae/

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2.5.2 HM&MR committee members who breach or are suspected of breaching the confidentiality

requirements of the committee will be removed from the committee pending the outcome of

a formal investigation, set up by the Hospital Director.

2.5.3 All proceedings, records, information, data, reports, recommendations, evaluations, opinions,

and findings of the hospital, and morbidity, mortality, and sentinel events reviews are strictly

confidential and are not subject to disclosure or discovery or introduction as evidence in any

civil action.

3. Definitions:

3.1 Morbidity: is an incidence of ill health, a complication or undesirable side effect following

surgery or medical treatment.

3.2 Mortality: is incidence of death in a population.

3.3 Sentinel Event: an unexpected occurrence involving death or serious physical or psychological

injury.

3.4 MOHAP: Ministry of Health and Prevention.

3.5 RCA: Root Cause Analysis.

3.6 HM&MR: Hospital Mortality and Morbidity Review.

3.7 CCGC: Central Clinical Governance Committee.

4. Procedure and Responsibility:

Procedure Sequence Responsibilities

Reporting and Reviewing process:

4.1 An identifiable morbidity, mortality or sentinel event that meets the

list (Appendix 1: Case Selection) will be reported through the

moderator to the HM&MR committee Chairperson within 24 hours

of the event or discovery of the event using the (Occurrence Variance

Report (OVR) and / or Sentinel Event Form).

Committee

Moderator or any

healthcare provider in

the hospital

4.2 The HM&MR committee Chairperson will assign a member from the

committee to do the initial review using the HM&MR worksheet part

A- C (see attachment 1)

HM&MR Committee

Chairperson

4.3 Mortality cases for further review shall be discussed with the

chairperson of the committee and sent to Peer Review for feedback

within 5 working days.

HM&MR Committee

Chairperson

4.4 All Mortality cases reviewed by the committee members shall be

presented in the HM&MR ( e.g. the HM&MR meeting in April shall

review mortality cases for the month of March ).

HM&MR Committee

4.5 Part D shall be discussed and completed in the meeting and signed

off by the committee members (see attachment 1). HM&MR Committee

4.6 Part E and Part F shall be also filled in the meeting and approved by

the Committee members (see attachment 1) . HM&MR Committee

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4.7 Committee moderator shall follow all action plans and the status of

implementation and present it on monthly basis to the committee

chairperson.

Committee

Moderator/

Coordinator

4.8 For sentinel events, a thorough and credible RCA shall be conducted

by the HM&MR committee and submitted 45 days of the event or

its discovery as per the Sentinel Event Policy and Procedure.

HM&MR Committee

Reporting Structure:

4.9 The Committee will make recommendations to the appropriate

committees at the hospital and MOHAP levels, and other relevant

clinical groups as defined.

HM&MR Committee

Members

4.10 The Committee will send Monthly reports on the approved forms

(see attachment 2) along with the minutes of meeting; the action

plan & feedback form and Root Cause Analysis (RCA) form to the

Central Clinical Governance Committee (CCGC) and Hospitals

Department/ MOHAP.

HM&MR Committee

Members

4.11 Analysis of reports should be conducted to assure that overall system

improvements are implemented, implementation is evaluated, and

training needs are incorporated into educational planning for the

hospitals.

HM&MR Committee

Members

4.12 An annual report shall be prepared by the chairperson and other

members as assigned by the chairperson and submitted to the CCGC/

MOHAP, which includes:

4.12.1 Summary of implemented action plans.

4.12.2 Classification of hospital morbidities with activities carried

out by the committee to reduce their occurrences.

4.12.3 Inpatient mortality rate and measures implemented to reduce

the occurrence.

4.12.4 Number of sentinel events and RCA conducted.

4.12.5 Number of major patients’ complaint.

4.12.6 Training programs conducted as part of the action plan.

HM&MR Committee

Members

5. Tools/Attachments Forms:

5.1 Appendix 1: Case selection

5.2 Appendix 2: M&MR Work Flow Chart

5.3 Attachment 1: Hospital Morbidity and Mortality Review Worksheet

5.4 Attachment 2: Hospital Morbidity and Mortality Reporting Form

6. References:

6.1 Morbidity and Mortality Terms of Reference

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7. Revision History:

New Policy Edition Date:

Remarks (if any)

Revised Policy Date of Revision:

Date of 1st Edition: Revision Number:

Policy and

Procedure

Status

Change Reference Section

8. Performance Indicator:

8.1 Decreased mortality rate

8.2 Reduction in medical malpractice claims

8.3 Patient satisfaction rate

8.4 Decreased mortality rate of cases occurring within 48 hours of admission

8.5 Reduction of hospital acquired infection

8.6 100% compliance to reporting cause of death as per WHO classification

9. Search Words:

Nil

Prepared by: Hospitals Department

Signature: Date:

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Approved by: Dr. Kalthoom Al Balooshi

Designation: Director of Hospitals’ Department

Signature: Date:

Authorized by: Dr. Yousif Mohammed Al Serkal

Designation: Assistant Undersecretary for Hospital Sector

Signature: Date:

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Appendix 1: Case Selection:

Mortalities Cases:

1. Inpatient death, Death in ER.

2. Cause of death has not been determined.

3. Death in the operating/procedure room.

4. Death within 2 weeks of surgery and resulting from surgery or anesthesia.

5. Maternal death (related to the birth process): the death of a woman while pregnant or within 42

days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from

any cause related to or aggravated by the pregnancy or its management but not from accidental

or incidental causes.

6. Peri-Natal death unrelated to a congenital condition in an infant having a birth weight greater

than 2,000gms.

7. Suicide for in-patient or within 72 hours of inpatient discharge.

8. Death on arrival for patients admitted within 28 days earlier with the same condition.

9. Death within 48hours from admission.

10. Death within 48 hours of a surgical or invasive procedure, including radiology.

11. Death associated with adverse event or drug reaction.

Morbidity Cases:

1. Significant Medication errors which resulted in the following ( long term disability , threat to

life , intervention to prevent serious harm, multiple permanent injury , impacts on a large

number of patients , increase hospital stay).

2. Hospital acquired infection.

3. Hospital acquired pressure ulcers.

4. Perioperative pulmonary embolism / secondary DVT for in-patient.

5. Unscheduled return to the OT/procedure room within the same admission.

6. Unplanned readmissions for same condition within 28 days of discharge.

7. Post- operative myocardial infarction occurring within 24 hours of anesthesia.

8. Unexpected cardiac arrest: cardiac arrest occurring outside the critical area excluding patients

who are prone to cardiac arrest but kept out of critical care due to clinical or palliative reasons.

9. Adverse events during moderate or deep sedation and anesthesia use.

10. Significant equipment faults that resulted in patients harm.

11. Surgical Site Infection.

12. Infectious disease outbreaks.

13. Adverse events during/after procedures.

14. Hemolytic transfusion reaction involving administration of blood or blood products having

major blood group incompatibilities.

15. Prolonged fluoroscopy with cumulative dose> 1500rads to a single field or any delivery of

radiotherapy to the wrong body region or >25% above planned radiotherapy dose.

Sentinel events( Policy Number USO/Admin/013):

1. Death that is unrelated to the natural course of the patient’s illness.

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2. Unanticipated Perinatal Death.

3. Death of a full-term infant.

4. Suicide of any patient receiving care, treatment and services or within 72 hours of discharge.

5. Major permanent loss of function unrelated to the patient’s natural course of illness or

underlying condition.

6. Wrong-site, wrong-procedure, wrong-patient surgery.

7. Unintended retention of a foreign object in a patient after surgery or other procedure.

8. Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter).

9. Maternal death or serious morbidity associated with labor or delivery.

10. Any patient paralysis , come , or other major permanent loss of function associated with a

medication error.

11. A patient fall that result in death or major permanent loss of function.

12. Infant abduction or an infant sent home with the wrong parents.

13. Rape, workplace violence such as assault (leading to death or permanent loss of function).

14. Major Service failure events that include Fire, Gas leakage, Chemical spillage, and electrical

shutdown causing structural damage, potential or actual harm to patients/ staff and or

compromising organization reputation.

In addition to these: major patients’ complaints, medico-legal cases and cases with the possibility

of quality improvement or those with some form of educational variable.

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Appendix 2: M&MR Workflow Chart

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Attachment 1:

Hospital Morbidity and Mortality Review Worksheet

(Filled by the HM&MR Committee)

Hospital Name:

Date:

Case – Check as appropriate:

Mortality

Morbidity

Sentinel event

Adverse event

Patient complaint

Patient Name :

File No : Nationality :

Age :

Sex : M F

Adm. Date :

Date of event:

Or Death Date :

Specialty :

Attending physician :

MRP :

Admission Diagnosis :

Diagnosis following the event :

Severity of illness as coded by 3M: Risk of mortality as coded by 3M:

Cause of Death:

Direct cause:

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Leading Cause:

Actual Cause:

Other significant:

Code blue initiated : Yes No N/A

PART A: Case Review (filled by M&M member):

S ( situation):

B (Background):

A (Assessment & analysis):

R (Recommendation):

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PART B: please answer (yes / No/ Not sure), Elaborate as needed (answered by the HM&M reviewing

member)

1. Was the patient previously admitted within 30 days?

2. Did the event (adverse event or death) occur within 48 hours of admission?

3. Did the event/Death occur within 48 hours of a surgical or invasive procedure?

4. Did the event/Death occur within 2 weeks of surgery and resulting from surgery or anesthesia

5. Was the patient accepted to ICU from AE department?

6. Was the patient transferred from ward to ICU within 24 hours of admission?

7. Was the patient held in emergency department greater than 4 hours?

8. Was the patient’s death a direct result of presenting illness?

9. Was the patient’s death related to an unexpected complication?

10. Was the standard of care demonstrated by the provider(s)?

11. Was death preventable?

12. Was death due to an adverse event/ sentinel event?

13. If death was due to an adverse event, (check all that apply) :

Delay in diagnosis

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Error in interpretation of data/diagnostic studies

Procedural error

Delay in action/intervention

Medication error (How so? Dose? Drug interaction? Inadequate monitoring?)

Was clinical Pharmacist involved in the care?

14. If error or adverse event, was there any documentation of disclosure (Was patient or family informed? If so,

how? If not, why?)

15. What did you learn from the experience that will help prevent a similar error from Occurring in the future?

What are the key lessons for the organization?

Key lessons:

Name of reviewer/s ……………………………………………………………………

Date Reviewed ………………………………………………………………………...

__________________________________________________________________________________________

PART C: Conclusion (filled by the HM&MR Committee)

For all events. Choose only one

YES NO Check appropriate box for response

Acceptable medical care

Acceptable medical care although complication(s) developed

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Suboptimal care : but different management would have made NO DIFFERENCE to the outcome

Suboptimal care : Different management probably have changed the outcome

PART D: Disposition of cases (filled by the HM&M Committee)

YES NO Check appropriate box for response

No Further Review Necessary.

For further investigation ( peer Review )

Root Cause Analysis RCA {for sentinel event}

PART E: Action plan and recommendations (filled by the HM&M Committee) :

Action plan and recommendations:

Reviewers: Members of the committee

Name Designation Signature

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Instructions for filling the Review Form:

1. An identifiable morbidity, mortality or sentinel event that meets the list set out above will be reported

through the moderator to the HM&MR committee Chairperson within 24 hours of the event or discovery

of the event using the (Occurrence Variance Report (OVR) and / or Sentinel Event Form).

2. The HM&MR committee Chairperson will assign a member from the committee to do the initial review

using the HMMR worksheet part A- B.

3. Part C-E shall be discussed and completed in the meeting and signed off by the committee members.

4. Cases for further review shall be discussed with the committee and sent to Peer Review for feedback with

5 working days.

5. All cases reviewed by the committee members shall be presented in the HM&MC ( e.g. the HM&MC

meeting in April shall review mortality cases for the month March )

6. Committee moderator shall follow all action plans and the status of implementation and present it on

monthly basis to the committee chairperson.

7. For sentinel events, a thorough and credible Root- Cause analysis shall be conducted by the HM&MR

committee and submitted 45 days of the event or its discovery as per the Sentinel Event Policy and

Procedures.

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Attachment 2: Hospital Morbidity and Mortality Reporting Form

Hospital Morbidity Data

Hospital Name:

S.

No. Morbidity Definition

Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec

1 Unscheduled return to

OT/Procedure room.

Number Admitted patients (not day-case surgeries)

returned to OT/Procedure room

2 Unintended retention of a foreign

object in a patient after surgery or

other procedure

3 Adverse events during moderate or

deep sedation and anesthesia use

4 Perioperative pulmonary embolism /

secondary DVT for in-patient

5 Post- operative myocardial infarction

occurring within 24 hours of

anesthesia

6 Adverse events during/after

procedures.

7 Unplanned readmission for same

condition within 30 days.

Number of unplanned readmission within 30 days of

discharge for the same condition

8 Return to ICU within 48hours of

transfer out of ICU Number of readmitted ICU cases within 48hours

9 Severe neonatal hyperbilirubinemia bilirubin >30 milligrams/deciliter,( > 513µmol / L)

10 Serious maternal morbidity

associated with labor or delivery

11

Significant Medication errors

Number Medication errors reported as significant

which resulted in any of the following ( long term

disability , threat to life , intervention to prevent

serious harm, multiple permanent injury , impacts on

a large number of patients , increase hospital stay

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12 Hemolytic transfusion reaction

involving administration of blood or

blood products having major blood

group incompatibilities.

13 Prolonged fluoroscopy / delivery of

radiotherapy to the wrong body

region

Prolonged fluoroscopy with cumulative dose>

1500rads to a single field or any delivery of

radiotherapy to the wrong body region or >25% above

planned radiotherapy dose.

14 Significant equipment faults that

resulted in patients harm

15

Unexpected cardiac arrest.

Cardiac arrest occurring outside the critical area

excluding patients who are prone to cardiac arrest but

kept out of critical care due to clinical or palliative

reasons.

16

Patient falls

Number of patient fall and injuries in the healthcare

facilities that resulted in extended hospital admission

and or death

17 Hospital acquired pressure ulcers Pressure ulcer noted only after admission or during

the hospital stay

18 SENTINEL EVENT Number of Sentinel Events identified

19 Root Cause Analysis ( yes or No )

20 Hospital acquired infection.

all nosocomial infections occurring 48 hours after

admittance.

21

Surgical Site Infections (SSIs)

Definition : Infections that occur in the wound created

by an invasive surgical procedure are generally

referred to as surgical site infections (SSIs).

22 Ventilator associated Pneumonia. Number of VAP in the hospital

23 Urinary Catheter-Associated

Urinary Tract Infection (CA-UTI) . Number of CA-UTI in the hospital

24 Central Line-Associated Blood

Stream Infection (CLA-BSI). Number of CLA-BSI in the hospital

25 Hospital Acquired MRSA infection

26 Major patients’ complaints number of major patients complaints

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Hospital Mortality Report

Hospital Name :

S.

No. Mortality Definition

Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec

1 Total number of all deaths

Inpatient death and death in AE (excluding still

births)

2 Inpatient deaths The number of inpatients who died in the hospital

3 Death in the operating /Procedure

Room

4 Death within 48 hours of a surgical

or invasive procedure, including

radiology

5 Death within 2 weeks of surgery and

resulting from surgery or anesthesia

6 Death on arrival for patients

admitted earlier within 28 days with

the same condition

7 Death within 48 hours from

admission

8 Brought dead to hospital

9 Death associated with adverse event

or drug reaction

10

Maternal death (related to the birth

process):

Death of a woman while pregnant or within 42 days

of termination of pregnancy, irrespective of the

duration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or its

management but not from accidental or incidental

causes

11 Number of Perinatal mortalities total number of perinatal mortalities

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12

Perinatal mortality Rate

The World Health Organization defines perinatal

mortality as the "number of stillbirths and deaths in

the first week of life per 1,000 live births, the

perinatal period commences at 24completed weeks of

gestation and ends seven completed days after

birth",[The PNMR refers to the number of perinatal

deaths per 1,000 total births

13 Still births

A stillbirth is a baby born dead after 24 completed

weeks gestation and weighing at least 500 grams.

14 Neonatal death

The death of a live-born baby within the first 28 days

of life

15

Suicide for in-patient or within 72

hours of inpatient discharge

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حصر الوفيات

Hospital Name :

#

Name Patient

file

Admission

date and

time

Date

and

time

of death

Age : plz

specify (

Y/M/D)

Gender Nationality Specialty Admission Diagnosis

Cause of death

{direct,

leading,

actual, cause

and other significant

causes

Case

Reviewed ( YES / NO

)

Death

within

48hours from

admission

?

Death within 48

hours of a

surgical or invasive

procedure ,

including radiology ?

Was death

associated with

adverse/ sentinel

event or drug reaction ?

Under optimal

conditions

would this death have

been

preventable

Death

Expected or

Not ?

conclusion

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

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Sep-18

Oct-18

Nov-18

Dec-18

Documents

Policy and Procedure Title: Mortality and Morbidity Review