Despite the best effort and intentions of a veterinary practice team, unfortunately not all procedures produce the desired outcome.
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It can be instructive for the veterinary team and comforting to the client to have the practice carry out a mortality/morbidity meeting on cases where the outcome of the procedure is either unexpected death or unforeseen serious complications.
These meetings need to be carried out in a timely fashion and in a manner so as not to threaten the staff involved in the case in question.
Ideally a small committee chaired by a senior veterinary surgeon/partner should be established in the practice to chair such meetings. It can be very useful to have an outside member of the committee as well. For example, this could be either a retired colleague or a member of the practice client liaison committee.
It is important that the chair establish ground rules at the beginning of the meeting to ensure that the meeting is open, honest and blame-free and that feedback is fair and constructive.
The successful mortality/morbidity meeting should:
- Encourage honesty and transparency
- Focus on improving systems and procedures rather than apportioning blame
- Use a systems approach to enable effective team learning and to develop recommendations for improvements and actions going forward
Some examples of the types of cases to consider are:
- Unexplained death
- Patients whose discharge from the practices was delayed due to serious complications
- Post-operative complications
- A return to theatre for the same problem before initial discharge
Before the meeting and as soon as possible after the unfortunate event, all staff involved should prepare a written report of their view of the event. As many of the involved staff as possible should be encourages to attend the meeting.
In addition, all clinical notes pertaining to the case in question should be made available before the meeting to all staff who will be attending the meeting.
Detailed minutes should be taken at the meeting so that any conclusions may be drawn, and a detailed report produced.
Mortality/morbidity meetings should be a useful tool for practices in addition to the clinical audits required by the RCVS Practice standards Scheme.
Forms help structure these meetings can be found on the BVHA members only secure area.