Informing best practice for conducting morbidity and mortality reviews: a literature review*Corey W. Joseph A B , Marie L. Garrubba A and Angela M. Melder A
Australian Health Review - https://doi.org/10.1071/AH16193
Submitted: 2 September 2016 Accepted: 24 February 2017 Published online: 20 April 2017
Objective Preventable hospital mortality is a critical public health issue, particularly when mortalities are associated with events that are preventable. Mortality and morbidity reviews (MMRs) provide a rigorous, systematic, open, collaborative and transparent review process for clinicians to examine areas of improvement. The aim of the present review was to explore the evidence for best practice when conducting MMRs.
Methods Searches of published and grey literature from 2009 to February 2016 were conducted. This period was selected to update a previous review. Inclusion and exclusion criteria was established a priori and based on the Population-Intervention-Comparison-Outcome (PICO) framework. Specific search terms were generated and used to identify relevant articles, with reference lists and citing articles also screened for inclusions. Titles and abstracts were screened and duplicates removed. Study details regarding setting, study design, reported outcomes, tool type, clinicians present and the timing of MMRs were extracted and summarised.
Results After screening, 31 documents were included in the present review: 20 peer-reviewed articles and 11 items from the grey literature. Specific outcomes reported included mortality rates, satisfaction, education, cost and quality of care. The most common features of MMRs included timing, leadership, attendees, case presentation format, terms of reference, agenda and governance.
Conclusions MMRs decrease gross mortality rates and are effective in identifying and engaging clinicians in system improvements. MMRs should not focus on the actions of individuals, rather on education and/or quality improvement. MMRs should consist of a multidisciplinary team following a structured presentation format with an analysis of error process including actions to be followed-up. Further, it is possible for a single standardised MMR to be implemented hospital wide.
What is known about the topic? MMRs are conducted in a variety of clinical settings to educate clinicians and improve patient care.
What does this paper add? This review updates a previous review published in 2009 and summarises current evidence around morbidity and mortality reviews. This review also provides a framework for a standardised MMR to be implemented hospital wide.
What are the implications for practitioners? This summary of the evidence can be used to guide the development, formation or conduct of MMRs in any healthcare setting.
References Higginson J, Walters R, Fulop N. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf 2012; 21 576–85.
| Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?CrossRef |
 Emergency Care Institute New South Wales. ED quality framework. Available at: http://www.ecinsw.com.au/sites/default/files/field/file/Standardised%20Death%20Reviews%20in%20ED%20resources_1.pdf [verified 29 July 2015].
 Robinson G, Davidge M, Davies J, et al. Providing assurance, driving improvement. Learning from mortality and harm reviews in NHS Wales. Cardiff: NHS Wales; 2013.
 Antonacci AC, Lam S, Lavarias V, et al A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. J Surg Res 2009; 153 95–104.
| A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.CrossRef |
 Berenholtz SM, Hartsell TL, Pronovost PJ. Learning from defects to enhance morbidity and mortality conferences. Am Coll Med Qual 2009; 24 192–5.
| Learning from defects to enhance morbidity and mortality conferences.CrossRef |
 Marini H, Merle V, Derrey S, et al Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality–morbidity conference: results of a pilot survey. BMJ Qual Saf 2012; 21 432–8.
| Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality–morbidity conference: results of a pilot survey.CrossRef |
 McVeigh TP, Waters PS, Murphy R, et al Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. J Am Coll Surg 2013; 216 50–6.
| Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference.CrossRef |
 Mitchell EL, Lee DY, Arora S, et al SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations. Am J Surg 2012; 203 26–31.
| SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.CrossRef |
 Pal KMI, Pardhan A, Mazahir S, et al Morbidity meetings: what makes it to; what stays out of the forum. J Pak Med Assoc 2013; 63 161–4.
 Nimptsch U, Mansky T. Quality measurement combined with peer review improved German in-hospital mortality rates for four diseases. Health Aff 2013; 32 1616–23.
| Quality measurement combined with peer review improved German in-hospital mortality rates for four diseases.CrossRef |
 Chan LS, Elabiad M, Zheng L, et al A medical staff peer review system in a public teaching hospital – an internal quality improvement tool. J Healthc Qual 2014; 36 37–44.
| A medical staff peer review system in a public teaching hospital – an internal quality improvement tool.CrossRef |
 Nolan SW, Burkard JF, Clark MJ, et al Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates. J Nurs Adm 2010; 40 374–83.
| Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates.CrossRef |
 Seigel TA, McGillicuddy DC, Barkin AZ, et al Morbidity and mortality conference in emergency medicine. J Emerg Med 2010; 38 507–11.
| Morbidity and mortality conference in emergency medicine.CrossRef |
 Ksouri H, Balanant P-Y, Tadie J-M, et al Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice. Am J Crit Care 2010; 19 135–45.
| Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice.CrossRef |
 Pekmezaris R, Cooper L, Efferen L, et al Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study. Palliat Support Care 2010; 8 421–6.
| Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study.CrossRef |
 Gupta M, Fuchs B, Cutilli C, et al Preventable mortality: does the perspective matter when determining preventability? J Surg Res 2013; 184 54–60.
| Preventable mortality: does the perspective matter when determining preventability?CrossRef |
 Mitchell EL, Lee DY, Arora S, et al Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Acad Med 2013; 88 824–30.
| Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.CrossRef |
 Schwarz D, Schwarz R, Gauchan B, et al Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Qual Saf 2011; 20 1082–8.
| Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement.CrossRef |
 Sellier E, David-Tchouda S, Bal G, et al Morbidity and mortality conferences: their place in quality assessments. Int J Health Care Qual Assur 2012; 25 189–96.
| Morbidity and mortality conferences: their place in quality assessments.CrossRef |
 Travaglia J, Debonoj D. Mortality and morbidity reviews: a comprehensive review of the literature. Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales; 2009.
 Moher D, Liberati A, Tetzlaff J, et al Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151 264–69.
 Murayama K, Derossis A, DaRosa D, et al A critical evaluation of the morbidity and mortality conference. Am J Surg 2002; 183 246–50.
| A critical evaluation of the morbidity and mortality conference.CrossRef |
 Deis J, Smith K, Warren M, et al. Transforming the morbidity and mortality conference into an instrument for systemwide improvement. In Henriksen K, Battles J, Keyes M, Grady M, editors. Advances in patient safety: new directions and alternative approaches, Vol. 2: culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
 Huddleston J, Diedrich D, Kinsey G, et al Learning from every death. J Patient Saf 2014; 10 6–12.
| Learning from every death.CrossRef |
 McDonnell C, Laxer RM, Roy WL. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Joint Comm J Qual Patient Saf 2010; 36 117–25.
| Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.CrossRef |
 Canadian Medical Protective Association. Learning from adverse events: fostering a just culture of safety in Canadian hospitals and health care institutions. Ottowa: Canadian Medical Protective Association; 2009.
 Dargon P, Mitchell E, Sevdalis N. Mortality and morbidity conference manual v.1.1. London: Oregon Health and Science University & Imperial College London; 2012.
 The Department of Health & Human Services State Government of Victoria. Understanding clinical practice toolkit. Melbourne: State Government of Victoria.
 Mills S. Maternal death audit as a tool: reducing maternal mortality. HNPNotes 2011; 1–10.
 National Office of Clinical Audit. Irish audit of surgical mortality. 2012. Available at: M&M%20Review%20Tools\National%20Office%20of%20Clinical%20Audiit%20Ireland%20Process_Flow_Chart.pdf [verified 8 March 2017].
 MedPro Group. Peer review in group practices. Patient safety & risk solutions. Fort Wayne: MedPro; 2014.
 Ferguson K, Arora S, Mitchell E, Sevdalis N. Anaesthesia morbidity and mortality meetings: a practical toolkit for improvement. London: The Royal College of Anaesthetists; 2013.
 The Royal Children’s Hospital Melbourne. Departmental morbidity & mortality review. Melbourne: The Royal Children’s Hospital; 2013.
 Yale-New Haven Hospital. Peer review & ongoing professional practice evaluation: Yale–New Haven Hospital, Department of Physician Services. 2013. Available at: http://extranet.acsysweb.com/vSiteManager/YNHH/Public/Upload/Images/Professionals/OPPE.pdf [verified 8 March 2017].