Emergency Department Morbidity and Mortality Meeting

The Morbidity and Mortality meeting is held every month.  At present half of the meeting are on Wednesday 2pm at Nursing In Service session adn the other half in Thursday teaching.

Registrars present the cases for open discussion.  It is open to all ED staff and all staff are encouraged to attend.

The purpose of the M+M meeting is to identify any systemic issues which need to be addressed to prevent recurrence of a problem.  It is not to discuss personal performance of any ED team members (this is addressed in separately).

A report from the meeting is then generated and distributed to all ED staff.

The terms of reference and the mortality review policy can be found here. The Bendigo Health Screening tool can be found here. This provides useful direction about what to look at and present in case.

Cases

Cases are identified from any source but are commonly deaths, cases identified through the hospital Riskman system, cases identified at audit (eg SSOU represents), cases with MET calls within 6 hours, cases flagged by any other unit or individual.  If you have a case that needs review please contact the Director or NUM.

Instructions to registrars

Case identification

2 weeks before you are scheduled to present the M+M meeting identify cases by contacting the DEMT coordinating that months meeting.  This will also involve requesting the deaths in ED from Ruth Young or Di Price for the preceding month.  Specifically, if you are presenting mid June, then you would be asking for all deaths in May.

History Accumulation

Once the list of UR numbers is compiled, request the histories be marked out to the DEMT office for the M+M meeting through Ruth Young.

Review Histories

Once you have reviewed the histories contact the DEMT to be clear about what the issues are and why the case has been included in the M+M.

Create presentation

Include the following basic information:  UR number, Age, Date of presentation to ED, History and clinical course of the patient.  Always focus on relevant information that might be pertinent to how the case unfolded and led to inclusion in the audit.  Times of events and investigations, and who talked to who are often important.  You can use the formal Bendigo Health M+M template and ISBAR format if you want but make the slides relevant to ED presentation.

At the beginning of each case state why the case is being reviewed (the S of ISBAR).  Then fill in the background of how the case unfolded in a clear and concise fashion.  Like all case presentations, people can ask questions that you can expand on verbally as long as you know the case inside out.

If the death was clearly expected and not controversial in objective terms then keep the slides to 2 or 3.

Include images, ECGs and de-identified photos of charts in your presentation where relevant.

Include teaching points relevant to the case where appropriate.

Flag particular issues you and the DEMT think have contributed to the case.

Save presentation to G Drive

Clearly identify the date in the title and your name.

Save your presentation in the G Drive:  G Drive/ED/Morbidity and Mortality/Presentations/Year

Why?

Quality Assurance and Improvement are core skills of any clinician.  These skills are also assessed as part of your  ITA.  Conducting the M+M also gives you valuable insights into levels of documentation, process difficulties and how other people approach problems.