title: Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital.
abstract: BACKGROUND
  Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings.
  
  
  METHODS
  A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies.
  
  
  RESULTS
  During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died.
  
  
  CONCLUSIONS
  Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care.
authors.affiliation: Department of General Surgery, Edendale Hospital, Pietermaritzburg Metropolitan Complex, and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. damianclar@gmail.com.
authors.forename: Damian L
authors.initials: DL
authors.lastname: Clarke
authors.forename: Heidi
authors.initials: H
authors.lastname: Furlong
authors.forename: Grant L
authors.initials: GL
authors.lastname: Laing
authors.forename: Colleen
authors.initials: C
authors.lastname: Aldous
authors.forename: Sandie Rutherford
authors.initials: SR
authors.lastname: Thomson
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D005260:Female; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000379:methods*; D019300:Medical Errors / Q000009:adverse effects / Q000145:classification*; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D013019:South Africa; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000592:standards*; D055815:Young Adult