The Morbidity and Mortality Review: A crucial tool for improving patient safety and quality

Institutional mortality rates can be used to monitor the quality of hospital care. Morbidity and Mortality (M&M) review is crucial to the hospital’s quality and patient safety initiatives. A multi-disciplinary forum to discuss M&M better lends itself to the discussion that balances physician error and system failure. It is crucial to afford attendees opportunities for introspection/reflection while holding those responsible accountable without apportioning blame. This review was undertaken at the M&M conference conducted by the Department of Surgery at The Aga Khan University Hospital Nairobi, a tertiary teaching and referral hospital. All surgical residents and faculty attend the M&M conference. A standard reporting format is used for every case discussed at the departmental level and shared at the institutional level. Morbidities and Mortalities that are analyzed as being due to a system or administrative process failure or having potential medico-legal implications are subjected to a Root Cause Analysis. Recommendations from individual cases focus on measures that can prevent similar outcomes or adverse incidents or improve the care processes provided to this group of patients. These recommendations should resist the temptation to apportion blame to individuals. The department needs to construct the meetings to integrate the system and administrative issues underlying unexpected outcomes and discuss technical/clinical-related issues. Physicians who feel they work in a ‘safe’ environment are likelier to self-report events and offer them for discussion.