Morbidity and mortality meetings at Australian Major Trauma Centres

Data Request Date: Not applicable - AusTQIP Collaboration project

Data Provided: NA

Requested by: Dr Henry Bear (as BMedSci project), Dr Meng Tuck Mok, Mr Nathan Farrow, Professor Russell Gruen

Ethics Approval: Monash CF14/2652 - 2014001433 (sites HREC numbers not supplied to ensure anonymity)

Morbidity and mortality (M&M) meetings are held at all Australian major trauma centres and provide a forum to identify problems and improve practices. Meetings should focus on addressing factors in the system to prevent similar errors occurring, rather than individual culpability.

This project, a sub-project of the AusTQIP collaboration, set out to survey trauma leaders at each of four Australian major trauma centres regarding morbidity and mortality meeting practices. A systems approach was measured by assessing practices against the London Protocol for Systems Analysis of Clinical Incidents. Meeting participants were also surveyed regarding perceptions of the objectives and effectiveness of meetings.

The study found that cases were not routinely analysed for contributing system factors and that effective processes were not always used to correct problems that are identified. Meeting practices also varied between centres in terms of frequency, case selection criteria and use of audit filters. Despite this, participants generally viewed quality improvement as the most important aspect of the meetings.

This research was peer-reviewed and published in Trauma in 2017 (online) and in 2018 (in journal).

Bear H, Mok MT, Farrow N, Curtis K, Mitra B, Fitzgerald M, Gruen RL. Morbidity and mortality meetings at Australian major trauma centres: A proof of concept study. Trauma. 2018, Vol. 20 (4) 268-272