Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference

J Am Coll Surg. 2013 Jan;216(1):50-6. doi: 10.1016/j.jamcollsurg.2012.09.010. Epub 2012 Nov 2.


Background: The aim of this study was to investigate the impact of a validated complication proforma on surgical Morbidity and Mortality (M&M) conference reporting.

Study design: The ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program) 30-day complication proforma, when implemented, previously showed a 25% increase in morbidity and a 50% increase in mortality reporting. A pilot study introducing the paper-based proforma was undertaken, collecting prospective M&M data for 2,094 of 2,209 colorectal, upper gastrointestinal, breast, and vascular inpatients (94.7% compliance). A comparative analysis using the proforma vs traditional M&M data collection was used to compare accuracy of M&M data reporting.

Results: There was a 73% increase in morbidities reported using the proforma as compared with M&M reporting (547 vs 316), and an increase of 10.81% (37 vs 41) in the reporting of mortalities. Of those patients with morbidities (n = 278), 70.24% (n = 203) had at least 1 surgical intervention. The median length of stay in patients with morbidities was 12 vs 3 days in those with no morbidities.

Conclusions: We demonstrated that prospective standardized incident recording provides significantly more accurate assessment of M&M data compared with current reporting methods. This increased accuracy should favorably affect surgical performance indicators and casemix funding.

Publication types

  • Comparative Study
  • Evaluation Study

MeSH terms

  • Data Collection / methods*
  • Data Collection / standards
  • Forms and Records Control
  • Hospital Mortality*
  • Hospital Records / standards
  • Hospital Records / statistics & numerical data
  • Hospitals, University / standards*
  • Hospitals, University / statistics & numerical data
  • Humans
  • Ireland
  • Medical Records / standards
  • Medical Records / statistics & numerical data
  • Peer Review, Health Care*
  • Pilot Projects
  • Postoperative Complications / epidemiology*
  • Postoperative Complications / mortality
  • Prospective Studies
  • Quality Assurance, Health Care / methods*
  • Quality Assurance, Health Care / standards
  • Quality Assurance, Health Care / statistics & numerical data
  • Quality Improvement
  • Risk Management / methods*
  • Risk Management / standards
  • Risk Management / statistics & numerical data