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In maternity services, morbidity and mortality (M&M) review meetings play a crucial role in reducing avoidable harm, improving transparency and strengthening clinical governance; both locally and across the healthcare system.
The process of M&M review allows clinicians to evaluate and reflect on clinical practice and identify areas for improvement, without blame or individual focus.
Over recent years, M&M review meetings have been conducted in various forms and not necessarily in a consistent manner. The format of meetings has been at the discretion of individual hospitals, resulting in mixed participation and variation in their structure and outputs.
In late 2015 the Victorian Department of Health and Human Services (DHHS) engaged the Royal Women’s Hospital (the Women’s) to coordinate the implementation of a system-wide approach to standardizing maternal and perinatal M&M reviews, in rural and regional Victoria.
This occurred following a series of preventable deaths in a Victorian Maternity Service, highlighting the need for more rigorous processes surrounding the delivery of care for women and babies. The project is one of the largest quality and safety initiatives to be undertaken in Victorian rural and regional maternity services for some time.
Adjunct Professor (A/Prof.) Tanya Farrell, Executive Director of Nursing & Midwifery at The Women’s has been leading the project, looking at how M&M review meetings could be coordinated and implemented across the sector to drive further service improvements.
A/Prof. Farrell’s and her teams’ ongoing work in this space has focused on multiple cases of mortality and selected morbidity, reviewing the care provided and collectively establishing if improvements need to be recommended, both at a clinical and organizational level.
Throughout this process, the team has identified a package of recommendations for Maternity Services on how to deliver a more coordinated and consistent approach to M&M review and strengthen internal governance processes.
A/Prof. Farrell will present the findings of this work at the Obstetric Malpractice Conference due to take place 23-24 August 2018 in Melbourne.
In advance of her presentation, Farrell said, “Given the vital role of M&M review meetings in avoiding preventable harm, there is now, more than ever, a clear need for a consistent and transparent approach across the sector”.
“So far we have identified a number of recommendations centered on a variety of key areas from clinical practice to organization-wide escalation responses”.
“We hope these strategies will improve not only the process of undertaking robust M&M review meetings across the sector but that this will ultimately lead to safer and more responsive care for women and babies”.
Sharing the stage with A/Prof. Farrell is the Women’s Director of Regional Maternal & Perinatal Mortality & Morbidity Committees, Bree Bulle.
