Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital : general surgery
Background. Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. Methods. A structured template was developed...
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Published in | South African journal of surgery Vol. 51; no. 4; pp. 122 - 126 |
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Main Authors | , , , , |
Format | Journal Article |
Language | English |
Published |
Medpharm Publications
01.11.2013
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Online Access | Get full text |
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Summary: | Background. Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. Methods. A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies. Results. During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died. Conclusion. Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care. |
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ISSN: | 0038-2361 2078-5151 |