Morbidity & mortality – Do we show effective learning?

3^rd Annual Congress and Medicare Expo on Trauma and Critical Care

March 13-14, 2017 London, UK

Brian Wilkinson and Michelle Carey

Yorkshire and The Humber, UK

Posters & Accepted Abstracts: J Trauma Treat

Abstract :

Background: NHS organizations should demonstrate effective learning from incidents. Royal college guidance recommends the use of Morbidity and Mortality (M&M) reviews to identifying learning points from past events and areas for future improvement. It is recommended that M&M reviews are undertaken on at least a monthly basis. Our critical care unit conducts a weekly, multidisciplinary, consultant-led morbidity and mortality meeting in order to encourage timely review of cases to identify learning points and implement action points. The M&M meeting seeks to review all deaths within a two-week period, and aspires to serve as a comprehensive clinical governance forum for policy discussion, audit presentation and incident review. Aim: Aim of this study is to assess whether the critical care morbidity and mortality meetings at MTC James Cook University Hospital, South Tees Hospitals NHS Foundation Trust develop learning and drive organizational change. Methods: A retrospective analysis of the unit M&M meeting database 01/05/2014 � 30/09/2015 was undertaken in order to identify learning points and to assess if there is evidence that highlighted action points were implemented. Thematic analysis was undertaken to analyze learning points and policy interventions. Results: 344 cases and topics were discussed at 71 M&M meetings. 100% of deaths were reviewed within two weeks. These included 318 mortality reviews (92.4%), three audit presentations (0.9%), 12 critical incident reviews (3.5%), eight policy discussions (2.3%) and three multidisciplinary discussions of complex patients (2%). A specific learning point was identified in 34.3% cases; the majority of learning points related to clinical management and/or documentation. Departmental action points were identifiable in 36.9% of cases. Departmental policy changes arising from M&M have encompassed a wide area including equipment, documentation, handover, radiology and microbiological guidelines. Conclusions: Weekly morbidity and mortality meetings can serve as a key clinical governance tool in ensuring effective organizational learning and can help drive organizational change.