Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association

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This article has been peer reviewed and accepted for publication. It is in production and has not been edited, so may differ from the final published form.

Informing best practice for conducting morbidity and mortality reviews. A literature review

Corey Joseph , Marie Garrubba , Angela Melder


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 our review was to explore the evidence for best practice when conducting MMRs. Methods. Searches 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 PICOS framework. Specific search terms selected were generated, and reference lists and citing articles were screened for inclusions. Titles and abstracts were screened and duplicates were 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, a total of 31 documents were included in this review (20 peer reviewed articles and 11 items of 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.

AH16193  Accepted 24 February 2017

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