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- W2169668664 abstract "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.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.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.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." @default.
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- W2169668664 date "2013-10-22" @default.
- W2169668664 modified "2023-10-14" @default.
- W2169668664 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" @default.
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- W2169668664 doi "https://doi.org/10.7196/sajs.1537" @default.
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