Morbidity and Mortality Meetings
Setting the Scene
June 14th 2019David Storey
Morbidity and Mortality Meetings
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.
Morbidity and Mortality Meetings
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
Morbidity and Mortality Meetings
This is not a true story, but it could be –
• 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
Morbidity and Mortality Meetings
This is not a true story, but it could be –
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
Morbidity and Mortality Meetings
This is not a true story, but it could be –
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
Morbidity and Mortality Meetings
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
Morbidity and Mortality Meetings
This is not a true story, but it could be –
Nine months later
• Dr Storey and the LHD receive a medicolegal claim
• The JMO’s M&M spreadsheets are demanded under subpoena
Morbidity and Mortality Meetings
This is not a true story, but it could be –
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
Morbidity and Mortality Meetings
This is not a true story, but it could be –
• Dr Storey retires from clinical practice and takes a position at the CEC as Clinical Advisor
• Nothing else changes.
Morbidity and Mortality Meetings
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
Morbidity and Mortality Meetings
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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Morbidity and Mortality Meetings
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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Morbidity and Mortality Meetings
• 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 ?