Analysing an adverse event in primary care: a multidisciplinary, collaborative process

Beyond detecting a healthcare-related adverse event, in-depth analysis (to determine which elements were preventable) sometimes requires the collaboration of all the healthcare professionals involved in the patient's care. The objective of collective, multidisciplinary analysis of healthcare-related adverse events is to improve patient safety; it is an extension of personal "reflexivity" (the ability to reflect on one's own actions). A morbidity and mortality conference (M&MC) is a means of collectively learning through errors; its aim is improve professional practice and quality of care. This approach is mainly used in hospitals, but it can be used by all healthcare professionals, including those in primary care, based on working procedures to be developed by the group concerned. Collective analysis of adverse events can improve communication, teamwork and promote a culture of safety among healthcare professionals. The problems detected can be of relevance to all the healthcare professionals involved.