[Morbidity/mortality reviews: assessment of their implementation in one hospital]

The objective of this study was to describe the steps involved in establishing a morbidity/mortality review committee (MMRC) to analyze the causes of avoidable deaths or life-threatening complications and the development of plans and protocols to avoid their recurrence.

The MMRC included physicians from each hospital department. Each member was responsible for organizing departmental meetings to analyze its avoidable deaths and life-threatening complications.

During its meetings three times a year, the MMRC developed a method for analysis of these serious events. Each department organized 3 (range: 1-12) meetings a year and analyzed 1-3 cases at each. Over 30 months, 35,817 patients were admitted to the hospital and 341 (1%) died. The unexpected mortality rate varied by department and specialty (median: 27%, range: 6-65%). In all, 92 cases were referred to MMRC meetings (27%; range: 6-70% of hospital deaths), and 30% of them involvement nosocomial diseases. Heart disease was the primary cause of unexpected deaths.

The principal improvements involved medical and surgical strategies, surgical techniques, drug prescriptions, and patient monitoring.