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Review
. 2016 Aug;32(4):272-277.
doi: 10.1159/000446997. Epub 2016 Jul 29.

Morbidity and Mortality Rounds in Liver Transplantation

Peri Kocabayoglu  1 , Martin Husen  2 , Oliver Witzke  3 , Andreas Kribben  3 , Fuat H Saner  1 , Ali Canbay  4 , Guido Gerken  4 , Andreas Paul  1
Affiliations
Review

Morbidity and Mortality Rounds in Liver Transplantation

Peri Kocabayoglu et al. Visc Med. 2016 Aug.

Abstract

Background: Morbidity and mortality conferences (MMCs) provide powerful opportunities for learning, reflection, and improvement. The current literature gives examples of how MMCs can be designed; however, no systematic review of cases and no original data related to liver transplantation are available. Liver transplantation requires a multidisciplinary approach to case identification, presentation, and analysis. Framework structures that guide case investigation are needed to successfully follow up on outcome measures and provide the basis for quality assessment and transparency in transplant programs.

Methods: All cases presented at our department's transplant-related MMCs in the years 2014 and 2015 were analyzed. Patient data were collected from our electronic database and meeting minutes. Cases were summarized according to type of transplantation. Liver-related transplant cases were analyzed for in-house deaths and time from death until presentation at an MMC. A literature review was performed, and our center's MMC design was compared with the literature available on conducting MMCs and improving patient safety and quality of care.

Results: Within 2 years, 15 MMCs were held at our department. 38 cases were discussed of which 25 were liver transplant-related. Most cases were in-house postoperative deaths, mainly due to sepsis or primary non-function. We provide a summary of recommendations for conducting MMCs based on conferences held in our department combined with the literature.

Conclusion: We present our experience with MMCs held over the past 24 months in consideration of guidelines on MMCs provided in the literature. As there is little conformity to known models for analyzing medical incidents, models for best practice in conduction MMCs are urgently needed.

Keywords: Healthcare quality improvement; Liver transplantation; Medical error; Morbidity and mortality conference; Patient safety.

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Figures

Fig. 1
Fig. 1
Causes of death (%) pertaining to cases of liver transplanted patients presented at our MMCs.
Fig. 2
Fig. 2
Important subjects that need to be addressed in order to conduct MMCs.
See this image and copyright information in PMC

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