DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20160033

Patient safety with special reference to adverse events taking place in the cases discussed in mortality and morbidity meets

Moonis Mirza, Farooq A. Jan, Fayaz Ahmad Sofi, Rauf Ahmad Wani

Abstract


Background: There is an increasing belief that an institution’s ability to avoid patient harm will be realized when it creates a culture of safety among its staff members. Aims to study the cases discussed in mortality meets.

Methods: Critical analysis of cases discussed in mortality and morbidity meet were done for one year by using WHO Structured questionnaire on patient safety (RF-1 & RF-2 forms) along with their record review and interview to the concerned staff.

Results: 62 mortality and morbidity meetings were conducted during the study period of one year. Cardiac/ Respiratory arrest was the most common adverse event studied (67.7%) followed by unexpected death (48.4%). 52.7% of studied adverse events showed signs of healthcare team responsible for causing adverse events, mainly related to the therapeutic care (64.8%). 47% of adverse events were categorized preventable.

Conclusions: Mortality and Morbidity Meets should be made mandatory in all hospitals.


Keywords


Mortality and Morbidity Meets, Patient safety, Preventable

Full Text:

PDF

References


World Health Organization (WHO). Patient Safety Curriculum Guide for Medical Schools; Part B: Curriculum Guide topics ; Topic 1, What is patient safety; WHO Library Cataloguing-in-Publication Data, Printed in France; WHO Patient Safety Curriculum Guide for Medical Schools 2009;1:80-98. Available online at:

http://www.who.int/patientsafety/activities/technical/who_ps_curriculum.pdf.

Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations; Qual Saf Health Care. 2003;12:17-23.

Pal KMI, Pardhan A. Morbidity meetings: What makes it to; what stays out of the forum; Journal of the Pakistan Medical Association JPMA. 2013;63:161.

Clarke DL, Furlong H, Laing GL. Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital; S Afr J Surg. 2013;51(4):122-6.

Deis JN, Smith KM, Warren MD. Transforming the Morbidity and Mortality Conference into an Instrument for System wide Improvement. Advances in Patient Safety: New Directions and Alternative Approaches. 2008;2.

Available from http://www.ncbi.nlm.nih.gov/books/NBK43710/

Risucci, DA, Sullivan T. Assessing educational validity of the Morbidity and Mortality conference: a pilot study. Current Surgery. 2003;60(2):204-9.