Sample ppt on how to do a mortality audit.

1. Mortality Audit
01-12-2022

2. What are Morbidity and Mortality
meetings?
Morbidity and Mortality meetings
(M&Ms) or clinical review meetings
allow departments/ specialties/
facilities to review the quality of the
care that is being provided to their
patients.
M&Ms are a key opportunity for
clinical staff to engage in the processes
of patient safety and quality
improvement and therefore represent
an important opportunity for
education regarding these processes
as well as for senior staff to model
appropriate professional behaviour.

3. Objectives
The objectives of a well-run M&M conference are to
identify adverse outcomes associated with medical error,
modify behavior and judgment based on previous
experiences, and prevent repetition of errors leading to
complications. Conferences are non-punitive and focus on
the goal of improved patient care. The proceedings are
generally kept confidential by law.
Meeting atmosphere conducive to open discussion with a
focus on “Just Culture” with an emphasis on the system,
not on individuals.
Shared understanding and enabling a positive
accountability team culture

4. Personal Details of the patient:

5. Final Diagnosis
Chronic Liver Disease (Alcohol
Related) – Decompensated with
Encephalopathy and Septic
Shock.

6. Critical Time
Line
• Date and time of admission onto Casualty:
23/11/22 7:10 pm
• Date and Time of Shifting to ward: HDU,
23/11/22 8:20 pm
• Any other shifts within wards: N/A
• Option of going to higher center given: Yes
• Date and Time of Death: 25/11/22, 1:05 pm
• Time Interval b/t admission & death: 41hrs
55min

7. Was the patient DNR: Yes,
Futility of care (Non-
availability of ventilators at
the time of admission)
Was it discussed with
family: Yes
History and Examination:
Chief complaints:
Abdominal distension
(insidious onset, no pain) &
Yellowish discoloration of
the sclera (no n pruritic).
Vitals: HR: 112, RR: 28, BP:
90/80, Spo2: Initially 71%-
later 92% with O2.
System: CVS: s1s2 +, RS:
Coarse Crepitations +, GI:
Abdomen Distended+++,
Gross ascites+++, CNS: E4
V4 M5

8. Provisional Diagnosis at Admission:
Chronic Alcoholic Liver disease in Shock with ARDS
Investigations:
• Hb: 10.8, TLC: 2.74, N: 91%, Platelets: 1.18 thousand.
• Creatinine: 1.08, Na: 127, K: 4.0
• LFT: Total Billirubin: 1.2, Direct. B: 0.5, Total Protein: 6.4, Albumin: 2.2
• AST: 51, ALT: 29, ALP: 104, INR: 1.89
• Ascitic Fluid: WBC: 50, DLC: Mostly Lymphocytes, Albumin: 0.6
• ABG: pH: 7.1, pCo2: 68.8, pO2: 65, HCO3: 23.7, SO2: 84%, Lactate: 3.64, BE: -5

9. ECG: N/A
CXR: B/L
pleural effusion
USG: N/A CT SCAN:N/A

10. Treatment
Given:
Inj. Piptaz 4.5g stat and Q8H
Inj.Pantop/ optineuron
Inj.Hydrocortisone
Inj. Vit K
Inj. Tranexa
Lactulose Enema

11. Course during hospitalization:
23/11/22
7: 10 pm: The patient was admitted to the ER after an
initial assessment by the duty doctor; Poor prognosis of
the patient and the non-availability of ventilator support
were explained to the patient relatives.
8:20 pm: patient shifted to HDU
24/11/22
12:35 am: Patient restless and desaturating: seen by the
duty doctor, BP: 120/90, SO2: 88%, PR: 120, O2 support
and Inj.Hydrocortisone given.
Morning Consultant Rounds: Patient Gasping, Diagnosed
to have lower GI bleed. Noradrenalin was started because
of BP: 80/50, Inj. Albumin, Inj. Octreotide was given, NIV-
BiPAP was started, and Hb checked Q8H.

12. 24/11/22
Evening: Blood Culture Report: gram-positive
cocci, Streptococcus Pneumoniae. Low urine
output(50 ml/ 12 hrs).
The patient is still on NIV and octreotide, and
noradrenalin infusion.
25/11/22
5 am: patient desaturated; relatives opted for
DNI, Noradrenalin at 40 mcg/min, octreotide
12.5
1pm: patient declared dead

13. Most
Important
treatment/
drugs for
the patient:
Pitaz
Hydrocortisone
Octreotide
Noradrenalin
NIV-BiPAP

14. • Time Interval b/w patient’s arrival in hospital and treatment /drugs
given: 15 min
• Was there any delay in treatment/drugs given: Yes
Antibiotics given after 1 hr, (1 hr 40 min
Delay in correction of Investigations: No

15. Documentation
• History & Examination: Adequate
• Doctor’s Orders: Adequate
• Operation notes: N/A
• Consent: Inadequate, High-risk consent
taken, No consent for Ascitic tap(probably
missed or misplaced).
• Death notes: Inadequate
• MLC Documentation: N/A
• Death certificate: N/A

16. Deficiencies in
Care Seen: Delay
in First does of
antibiotics
(Modifiable)
Technical: Non-
availability of
ventilator
(Limited
resource)- Not-
easily modifiable
Judgemental:
N/A
Monitoring: N/A

17. How can the Deficiencies be improved upon
the First dose of I/V
antibiotics should be
given immediately after
taking cultures – Gold
standard- within 1hr.
Re-check by nursing staff
if there is any deficient
documentation before
shifting the patient from
CR to ward/HDU.

18. Lessons
Learnt
Intravenous antibiotics, in case of
Sepsis, should be given at the
earliest possible time, preferably
within 1 hr, to decrease morbidity
and Mortality.
Check has to be made by the
nursing staff to ensure all
documents including consent forms
present in the file.

19. Potential Legal
implications?
N/A

20. Thank You
- Karthik Thangamuthu