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Jt Comm J Qual Patient Saf. 2010 Mar;36(3):117-25.

Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.

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Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto.



The concept of the morbidity and mortality (M&M) review is almost 100 years old, yet no standards describe "good practice" of M&M in clinical departments. Few reports measure output and impact of M&M reviews. The M&M activities were developed in a university-affiliated pediatric anesthesia department as part of a departmental quality improvement (QI) initiative. The process was designed to identify problems within the M&M program and to introduce interventions and actions to increase the program's efficiency and impact.


Through a series of interviews and consultation with hospital management, existing problems and inefficiencies were identified, a framework for developing the M&M program was established, and reportable outcome measures, such as increased meeting attendance, participation, self-reporting, and change to practice, were developed. Through appointment of specific M&M personnel, appointment ofa specific departmental M&M coordinator, meeting more regularly, stressing the review of system errors and close calls, and encouraging anonymous reporting, the department's M&M activities were redesigned.


From the (July 1) 2001-(June 30) 2006 to (July 1) 2006-(June 30) 2009 periods, case reviews and case presentations increased from a mean of 1.9 to 3.4 cases presented per M&M meeting. Meeting attendance increased from a mean of 5.1 to 25, and self-reporting from a mean of 22% of all safety reports received to 40%. Findings and recommendations were effectively disseminated throughout the department and hospital, reflecting the unique structure of the M&M program and personnel's efforts.


M&M QI with respect to data gathering, case review, and ongoing medical education is an efficient way to demonstrate quality assurance and creative professional development.

[Indexed for MEDLINE]

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