Auckland ED conducts regular Mortality and Morbidity Reviews. In these meetings, cases are presented and discussed where an adverse outcome has occurred, a ‘near-miss’ has occurred, or useful educational elements are present.

These meetings are confidential and legally privileged, and details will NOT be discussed on this site.

Case presentations have traditionally focused on clinical assessment and management issues and decision-making, however research into adverse events in medical environments reveals that systems and process issues also play a major part. With this in mind, our Mortality and Morbidity Reviews have three aims:

• to analyse cases for clinical, system, and process issues that need to remedied to prevent future events
• to educate medical and nursing staff in the concepts of Root Cause Analysis (RCA)
• to contribute to a culture of proactive risk identification and safety management so that hazards can be identified and mitigated before adverse events occur

The tool used for our case review is a fishbone diagram, which can be found here.

It was adapted for our use from a paper published in The American Journal Of Medicine in 2010.

Following presentation of the sequence of events of a case and relevant information, the audience is tasked with identify elements that may have contributed to an adverse event or near-miss, and the fishbone diagram is constructed in real-time for that case. Relevant guidelines or evidence are also accessed on the internet in real-time.

This serves the dual purposes of both generating a consensus opinion from multiple ED staff members, but also providing education in the principles of RCA. A further consensus opinion is then obtained regarding the severity of the event, and for recommendations to prevent further adverse events.

Root Cause of this event..?