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conferenceseries.com
March 13-14, 2017 London, UK
3rd Annual Congress and Medicare Expo on
Trauma & Critical Care
Volume 6, Issue 1 (Suppl) J Trauma Treat 2017
ISSN: 2167-1222, JTM an open access journal Trauma 2017
March 13-14, 2017
Morbidity & mortality – Do we show effective learning?
Brian Wilkinson and Michelle Carey
Yorkshire and The Humber, UK
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 andmortality meetings can serve as a key clinical governance tool in ensuring effective organizational
learning and can help drive organizational change.
J Trauma Treat 2017, 6:1 (Suppl)