24-28 oktober 2016
Vitenskapelige forhandlinger
Abstrakt nr:
211
TRAUMA MORTALITY AND MORBIDITY CONFERENCES - VITAL PART OF THE QUALITY IMPROVEMENT PROGRAM AT OSLO UNIVERSITY HOSPITAL Baksaas-Aasen K, Næss PA, Gaarder C Department of Traumatology, Oslo University Hospital, Oslo Background During Mortality and Morbidity (M&M) conferences adverse events, medical errors and system-based practice are evaluated in order to improve quality of care and patient safety. Methods The Department of Traumatology at Oslo University Hospital (OUH) has since 2010 conducted 8-10 M&M conferences annually. Core specialties involved in trauma care as well as the institutional Trauma Registry are represented during these conferences. The M&M conference manager reviews all trauma deaths, excluding only patients with obvious lethal brain injury and patients deemed dead on arrival. Other target categories include massive transfusion protocol activations, prehospital transfusions, accidental hypothermia, and any adverse events referred for assessment. Anonymized case summaries are prepared by the M&M conference manager using a dedicated assessment form. Every case is assigned one member of the M&M board, who present the case followed by a maximum 10 minute focused discussion aiming at identifying adverse outcomes and areas of improvement.
Conclusion We consider the M&M conferences to be indispensable to our ongoing quality improvement work. The discussions have to be focused and objective. The presence and contribution of dedicated representatives from all major specialties involved in trauma care are vital to balanced discussions and meaningful conclusions.
Høstmøte-2016-Innmat.indd 331
Traumatologi Maxillofascial kirurgi
Results During the 2 year period 2014-2015 a total of 250 patients were screened, of whom 60 were subsequently discussed at an M&M conference at OUH. Among these 60 patients, 37 were trauma related deaths. Mean Injury Severity Score for patients presented in the conferences was 34 for 2014 and 29 for 2015. For the period 2014- 2015 death was deemed preventable in one patient, probably preventable in one, and possibly preventable in 8 patients. A total of 47 adverse events and 29 ‘potentials for improvement’ were exposed. The identified areas of improvement included: educational deficit, need for adjustment of protocols, documentation deficit. The identified actions have been followed up by the involved departments.
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