policy and procedure title: mortality and morbidity review
TRANSCRIPT
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Mortality and Morbidity Review
Policy and Procedure Title: Mortality and Morbidity Review (M&MR)
Ownership:
Hospitals
Department
Effective Date: Code:
Revision Due Date: Type of Policy and procedure:
Administrative
Technical (Clinical) Done By: Hospitals Department
Applies to: All MOHAP Healthcare facilities
1. Purpose & Scope:
1.1 The purpose of M&MR varies, however the most common goals are: medical management,
teaching, patient safety and quality improvement.
1.2 An effective M&MR should: identify events resulting in adverse patient outcomes; foster
discussion of those events; identify and disseminate information and insights about patient care
that are drawn from experience; reinforce accountability for providing high-quality care, and create
a forum in which physicians acknowledge and address reasons for mistakes.
1.3 This policy applies to all hospitals in the MOHAP.
2. Policy Statement:
2.1 Hospitals M&MR reviews are conducted by the M&MR committee in each hospital.
2.2 The members of the Hospital Mortality and Morbidity Review (HM&MR) committee shall be
appointed by the hospital Director
2.3 It’s a multidisciplinary team; Participants include the providers involved in the care of the patient,
selected experts, and others who can contribute to the analysis of the event and to the development
of practical recommendations to improve patient safety.
2.4 Managing Conflict Of Interest:
2.4.1 HM&MR functions shall be carried in good faith, honestly and impartially and situations that
might compromise the integrity of these functions or lead to conflicts of interest should be
avoided.
2.4.2 When members of the committee believe they have a conflict of interest on a subject that will
prevent them from reaching an impartial decision or undertaking an activity consistent with
the Committee’s functions, they must declare the conflict of interest and withdraw
themselves from the discussion and/or activity.
2.4.3 Members of the committee shall attend meetings and undertake committee activities as
independent persons responsible to the committee as a whole. HM&MR Committee should
not, therefore, assume that a particular group's interests have been taken into account because
a member is associated with a particular group.
2.5 Confidentiality:
2.5.1 The statutory requirements from the HM&MR committee should be noted, which prevent
disclosure of information related to reviewed cases (refer to the document of “Professional
conduct and ethics principles for a general occupation” produced by the Federal Authority for
Government Human Resources, www.fahr.gov.ae).
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2.5.2 HM&MR committee members who breach or are suspected of breaching the confidentiality
requirements of the committee will be removed from the committee pending the outcome of
a formal investigation, set up by the Hospital Director.
2.5.3 All proceedings, records, information, data, reports, recommendations, evaluations, opinions,
and findings of the hospital, and morbidity, mortality, and sentinel events reviews are strictly
confidential and are not subject to disclosure or discovery or introduction as evidence in any
civil action.
3. Definitions:
3.1 Morbidity: is an incidence of ill health, a complication or undesirable side effect following
surgery or medical treatment.
3.2 Mortality: is incidence of death in a population.
3.3 Sentinel Event: an unexpected occurrence involving death or serious physical or psychological
injury.
3.4 MOHAP: Ministry of Health and Prevention.
3.5 RCA: Root Cause Analysis.
3.6 HM&MR: Hospital Mortality and Morbidity Review.
3.7 CCGC: Central Clinical Governance Committee.
4. Procedure and Responsibility:
Procedure Sequence Responsibilities
Reporting and Reviewing process:
4.1 An identifiable morbidity, mortality or sentinel event that meets the
list (Appendix 1: Case Selection) will be reported through the
moderator to the HM&MR committee Chairperson within 24 hours
of the event or discovery of the event using the (Occurrence Variance
Report (OVR) and / or Sentinel Event Form).
Committee
Moderator or any
healthcare provider in
the hospital
4.2 The HM&MR committee Chairperson will assign a member from the
committee to do the initial review using the HM&MR worksheet part
A- C (see attachment 1)
HM&MR Committee
Chairperson
4.3 Mortality cases for further review shall be discussed with the
chairperson of the committee and sent to Peer Review for feedback
within 5 working days.
HM&MR Committee
Chairperson
4.4 All Mortality cases reviewed by the committee members shall be
presented in the HM&MR ( e.g. the HM&MR meeting in April shall
review mortality cases for the month of March ).
HM&MR Committee
4.5 Part D shall be discussed and completed in the meeting and signed
off by the committee members (see attachment 1). HM&MR Committee
4.6 Part E and Part F shall be also filled in the meeting and approved by
the Committee members (see attachment 1) . HM&MR Committee
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Mortality and Morbidity Review
4.7 Committee moderator shall follow all action plans and the status of
implementation and present it on monthly basis to the committee
chairperson.
Committee
Moderator/
Coordinator
4.8 For sentinel events, a thorough and credible RCA shall be conducted
by the HM&MR committee and submitted 45 days of the event or
its discovery as per the Sentinel Event Policy and Procedure.
HM&MR Committee
Reporting Structure:
4.9 The Committee will make recommendations to the appropriate
committees at the hospital and MOHAP levels, and other relevant
clinical groups as defined.
HM&MR Committee
Members
4.10 The Committee will send Monthly reports on the approved forms
(see attachment 2) along with the minutes of meeting; the action
plan & feedback form and Root Cause Analysis (RCA) form to the
Central Clinical Governance Committee (CCGC) and Hospitals
Department/ MOHAP.
HM&MR Committee
Members
4.11 Analysis of reports should be conducted to assure that overall system
improvements are implemented, implementation is evaluated, and
training needs are incorporated into educational planning for the
hospitals.
HM&MR Committee
Members
4.12 An annual report shall be prepared by the chairperson and other
members as assigned by the chairperson and submitted to the CCGC/
MOHAP, which includes:
4.12.1 Summary of implemented action plans.
4.12.2 Classification of hospital morbidities with activities carried
out by the committee to reduce their occurrences.
4.12.3 Inpatient mortality rate and measures implemented to reduce
the occurrence.
4.12.4 Number of sentinel events and RCA conducted.
4.12.5 Number of major patients’ complaint.
4.12.6 Training programs conducted as part of the action plan.
HM&MR Committee
Members
5. Tools/Attachments Forms:
5.1 Appendix 1: Case selection
5.2 Appendix 2: M&MR Work Flow Chart
5.3 Attachment 1: Hospital Morbidity and Mortality Review Worksheet
5.4 Attachment 2: Hospital Morbidity and Mortality Reporting Form
6. References:
6.1 Morbidity and Mortality Terms of Reference
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7. Revision History:
New Policy Edition Date:
Remarks (if any)
Revised Policy Date of Revision:
Date of 1st Edition: Revision Number:
Policy and
Procedure
Status
Change Reference Section
8. Performance Indicator:
8.1 Decreased mortality rate
8.2 Reduction in medical malpractice claims
8.3 Patient satisfaction rate
8.4 Decreased mortality rate of cases occurring within 48 hours of admission
8.5 Reduction of hospital acquired infection
8.6 100% compliance to reporting cause of death as per WHO classification
9. Search Words:
Nil
Prepared by: Hospitals Department
Signature: Date:
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Mortality and Morbidity Review
Approved by: Dr. Kalthoom Al Balooshi
Designation: Director of Hospitals’ Department
Signature: Date:
Authorized by: Dr. Yousif Mohammed Al Serkal
Designation: Assistant Undersecretary for Hospital Sector
Signature: Date:
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Appendix 1: Case Selection:
Mortalities Cases:
1. Inpatient death, Death in ER.
2. Cause of death has not been determined.
3. Death in the operating/procedure room.
4. Death within 2 weeks of surgery and resulting from surgery or anesthesia.
5. Maternal death (related to the birth process): the death of a woman while pregnant or within 42
days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from
any cause related to or aggravated by the pregnancy or its management but not from accidental
or incidental causes.
6. Peri-Natal death unrelated to a congenital condition in an infant having a birth weight greater
than 2,000gms.
7. Suicide for in-patient or within 72 hours of inpatient discharge.
8. Death on arrival for patients admitted within 28 days earlier with the same condition.
9. Death within 48hours from admission.
10. Death within 48 hours of a surgical or invasive procedure, including radiology.
11. Death associated with adverse event or drug reaction.
Morbidity Cases:
1. Significant Medication errors which resulted in the following ( long term disability , threat to
life , intervention to prevent serious harm, multiple permanent injury , impacts on a large
number of patients , increase hospital stay).
2. Hospital acquired infection.
3. Hospital acquired pressure ulcers.
4. Perioperative pulmonary embolism / secondary DVT for in-patient.
5. Unscheduled return to the OT/procedure room within the same admission.
6. Unplanned readmissions for same condition within 28 days of discharge.
7. Post- operative myocardial infarction occurring within 24 hours of anesthesia.
8. Unexpected cardiac arrest: cardiac arrest occurring outside the critical area excluding patients
who are prone to cardiac arrest but kept out of critical care due to clinical or palliative reasons.
9. Adverse events during moderate or deep sedation and anesthesia use.
10. Significant equipment faults that resulted in patients harm.
11. Surgical Site Infection.
12. Infectious disease outbreaks.
13. Adverse events during/after procedures.
14. Hemolytic transfusion reaction involving administration of blood or blood products having
major blood group incompatibilities.
15. Prolonged fluoroscopy with cumulative dose> 1500rads to a single field or any delivery of
radiotherapy to the wrong body region or >25% above planned radiotherapy dose.
Sentinel events( Policy Number USO/Admin/013):
1. Death that is unrelated to the natural course of the patient’s illness.
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2. Unanticipated Perinatal Death.
3. Death of a full-term infant.
4. Suicide of any patient receiving care, treatment and services or within 72 hours of discharge.
5. Major permanent loss of function unrelated to the patient’s natural course of illness or
underlying condition.
6. Wrong-site, wrong-procedure, wrong-patient surgery.
7. Unintended retention of a foreign object in a patient after surgery or other procedure.
8. Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter).
9. Maternal death or serious morbidity associated with labor or delivery.
10. Any patient paralysis , come , or other major permanent loss of function associated with a
medication error.
11. A patient fall that result in death or major permanent loss of function.
12. Infant abduction or an infant sent home with the wrong parents.
13. Rape, workplace violence such as assault (leading to death or permanent loss of function).
14. Major Service failure events that include Fire, Gas leakage, Chemical spillage, and electrical
shutdown causing structural damage, potential or actual harm to patients/ staff and or
compromising organization reputation.
In addition to these: major patients’ complaints, medico-legal cases and cases with the possibility
of quality improvement or those with some form of educational variable.
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Appendix 2: M&MR Workflow Chart
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Attachment 1:
Hospital Morbidity and Mortality Review Worksheet
(Filled by the HM&MR Committee)
Hospital Name:
Date:
Case – Check as appropriate:
Mortality
Morbidity
Sentinel event
Adverse event
Patient complaint
Patient Name :
File No : Nationality :
Age :
Sex : M F
Adm. Date :
Date of event:
Or Death Date :
Specialty :
Attending physician :
MRP :
Admission Diagnosis :
Diagnosis following the event :
Severity of illness as coded by 3M: Risk of mortality as coded by 3M:
Cause of Death:
Direct cause:
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Leading Cause:
Actual Cause:
Other significant:
Code blue initiated : Yes No N/A
PART A: Case Review (filled by M&M member):
S ( situation):
B (Background):
A (Assessment & analysis):
R (Recommendation):
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PART B: please answer (yes / No/ Not sure), Elaborate as needed (answered by the HM&M reviewing
member)
1. Was the patient previously admitted within 30 days?
2. Did the event (adverse event or death) occur within 48 hours of admission?
3. Did the event/Death occur within 48 hours of a surgical or invasive procedure?
4. Did the event/Death occur within 2 weeks of surgery and resulting from surgery or anesthesia
5. Was the patient accepted to ICU from AE department?
6. Was the patient transferred from ward to ICU within 24 hours of admission?
7. Was the patient held in emergency department greater than 4 hours?
8. Was the patient’s death a direct result of presenting illness?
9. Was the patient’s death related to an unexpected complication?
10. Was the standard of care demonstrated by the provider(s)?
11. Was death preventable?
12. Was death due to an adverse event/ sentinel event?
13. If death was due to an adverse event, (check all that apply) :
Delay in diagnosis
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Error in interpretation of data/diagnostic studies
Procedural error
Delay in action/intervention
Medication error (How so? Dose? Drug interaction? Inadequate monitoring?)
Was clinical Pharmacist involved in the care?
14. If error or adverse event, was there any documentation of disclosure (Was patient or family informed? If so,
how? If not, why?)
15. What did you learn from the experience that will help prevent a similar error from Occurring in the future?
What are the key lessons for the organization?
Key lessons:
Name of reviewer/s ……………………………………………………………………
Date Reviewed ………………………………………………………………………...
__________________________________________________________________________________________
PART C: Conclusion (filled by the HM&MR Committee)
For all events. Choose only one
YES NO Check appropriate box for response
Acceptable medical care
Acceptable medical care although complication(s) developed
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Suboptimal care : but different management would have made NO DIFFERENCE to the outcome
Suboptimal care : Different management probably have changed the outcome
PART D: Disposition of cases (filled by the HM&M Committee)
YES NO Check appropriate box for response
No Further Review Necessary.
For further investigation ( peer Review )
Root Cause Analysis RCA {for sentinel event}
PART E: Action plan and recommendations (filled by the HM&M Committee) :
Action plan and recommendations:
Reviewers: Members of the committee
Name Designation Signature
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Instructions for filling the Review Form:
1. An identifiable morbidity, mortality or sentinel event that meets the list set out above will be reported
through the moderator to the HM&MR committee Chairperson within 24 hours of the event or discovery
of the event using the (Occurrence Variance Report (OVR) and / or Sentinel Event Form).
2. The HM&MR committee Chairperson will assign a member from the committee to do the initial review
using the HMMR worksheet part A- B.
3. Part C-E shall be discussed and completed in the meeting and signed off by the committee members.
4. Cases for further review shall be discussed with the committee and sent to Peer Review for feedback with
5 working days.
5. All cases reviewed by the committee members shall be presented in the HM&MC ( e.g. the HM&MC
meeting in April shall review mortality cases for the month March )
6. Committee moderator shall follow all action plans and the status of implementation and present it on
monthly basis to the committee chairperson.
7. For sentinel events, a thorough and credible Root- Cause analysis shall be conducted by the HM&MR
committee and submitted 45 days of the event or its discovery as per the Sentinel Event Policy and
Procedures.
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Attachment 2: Hospital Morbidity and Mortality Reporting Form
Hospital Morbidity Data
Hospital Name:
S.
No. Morbidity Definition
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
1 Unscheduled return to
OT/Procedure room.
Number Admitted patients (not day-case surgeries)
returned to OT/Procedure room
2 Unintended retention of a foreign
object in a patient after surgery or
other procedure
3 Adverse events during moderate or
deep sedation and anesthesia use
4 Perioperative pulmonary embolism /
secondary DVT for in-patient
5 Post- operative myocardial infarction
occurring within 24 hours of
anesthesia
6 Adverse events during/after
procedures.
7 Unplanned readmission for same
condition within 30 days.
Number of unplanned readmission within 30 days of
discharge for the same condition
8 Return to ICU within 48hours of
transfer out of ICU Number of readmitted ICU cases within 48hours
9 Severe neonatal hyperbilirubinemia bilirubin >30 milligrams/deciliter,( > 513µmol / L)
10 Serious maternal morbidity
associated with labor or delivery
11
Significant Medication errors
Number Medication errors reported as significant
which resulted in any of the following ( long term
disability , threat to life , intervention to prevent
serious harm, multiple permanent injury , impacts on
a large number of patients , increase hospital stay
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12 Hemolytic transfusion reaction
involving administration of blood or
blood products having major blood
group incompatibilities.
13 Prolonged fluoroscopy / delivery of
radiotherapy to the wrong body
region
Prolonged fluoroscopy with cumulative dose>
1500rads to a single field or any delivery of
radiotherapy to the wrong body region or >25% above
planned radiotherapy dose.
14 Significant equipment faults that
resulted in patients harm
15
Unexpected cardiac arrest.
Cardiac arrest occurring outside the critical area
excluding patients who are prone to cardiac arrest but
kept out of critical care due to clinical or palliative
reasons.
16
Patient falls
Number of patient fall and injuries in the healthcare
facilities that resulted in extended hospital admission
and or death
17 Hospital acquired pressure ulcers Pressure ulcer noted only after admission or during
the hospital stay
18 SENTINEL EVENT Number of Sentinel Events identified
19 Root Cause Analysis ( yes or No )
20 Hospital acquired infection.
all nosocomial infections occurring 48 hours after
admittance.
21
Surgical Site Infections (SSIs)
Definition : Infections that occur in the wound created
by an invasive surgical procedure are generally
referred to as surgical site infections (SSIs).
22 Ventilator associated Pneumonia. Number of VAP in the hospital
23 Urinary Catheter-Associated
Urinary Tract Infection (CA-UTI) . Number of CA-UTI in the hospital
24 Central Line-Associated Blood
Stream Infection (CLA-BSI). Number of CLA-BSI in the hospital
25 Hospital Acquired MRSA infection
26 Major patients’ complaints number of major patients complaints
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Hospital Mortality Report
Hospital Name :
S.
No. Mortality Definition
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
1 Total number of all deaths
Inpatient death and death in AE (excluding still
births)
2 Inpatient deaths The number of inpatients who died in the hospital
3 Death in the operating /Procedure
Room
4 Death within 48 hours of a surgical
or invasive procedure, including
radiology
5 Death within 2 weeks of surgery and
resulting from surgery or anesthesia
6 Death on arrival for patients
admitted earlier within 28 days with
the same condition
7 Death within 48 hours from
admission
8 Brought dead to hospital
9 Death associated with adverse event
or drug reaction
10
Maternal death (related to the birth
process):
Death of a woman while pregnant or within 42 days
of termination of pregnancy, irrespective of the
duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its
management but not from accidental or incidental
causes
11 Number of Perinatal mortalities total number of perinatal mortalities
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12
Perinatal mortality Rate
The World Health Organization defines perinatal
mortality as the "number of stillbirths and deaths in
the first week of life per 1,000 live births, the
perinatal period commences at 24completed weeks of
gestation and ends seven completed days after
birth",[The PNMR refers to the number of perinatal
deaths per 1,000 total births
13 Still births
A stillbirth is a baby born dead after 24 completed
weeks gestation and weighing at least 500 grams.
14 Neonatal death
The death of a live-born baby within the first 28 days
of life
15
Suicide for in-patient or within 72
hours of inpatient discharge
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حصر الوفيات
Hospital Name :
#
Name Patient
file
Admission
date and
time
Date
and
time
of death
Age : plz
specify (
Y/M/D)
Gender Nationality Specialty Admission Diagnosis
Cause of death
{direct,
leading,
actual, cause
and other significant
causes
Case
Reviewed ( YES / NO
)
Death
within
48hours from
admission
?
Death within 48
hours of a
surgical or invasive
procedure ,
including radiology ?
Was death
associated with
adverse/ sentinel
event or drug reaction ?
Under optimal
conditions
would this death have
been
preventable
Death
Expected or
Not ?
conclusion
Jan-18
Feb-18
Mar-18
Apr-18
May-18
Jun-18
Jul-18
Aug-18
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Sep-18
Oct-18
Nov-18
Dec-18