CC BY-NC-ND 4.0 · Eur J Dent 2021; 15(02): 307-311
DOI: 10.1055/s-0040-1719233
Original Article

Morbidity and Mortality Review in a University Dental Hospital: A Necessary Tool to Improve Quality of Care

1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
3   Laboratoire AMIS, CNRS, Toulouse, France
,
Marie-Cécile Valera
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
4   I2MC, CHU de Toulouse and Université de Toulouse, Toulouse, France
,
Jean Marc Bergia
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
,
Thibault Canceill
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
5   CIRIMAT, University of Toulouse, CNRS, INPT, Université Paul Sabatier, Faculté de Pharmacie, Toulouse, France
,
Leonor Costa Mendes
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
,
Isabelle Bailleul-Forestier
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
,
Virginie Gardette
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
6   UMR INSERM, Université Paul Sabatier, CHU de Toulouse, Hôtel-Dieu, Toulouse, France
,
Frédéric Vaysse
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
3   Laboratoire AMIS, CNRS, Toulouse, France
,
Marie Gurgel-Georgelin
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
,
Emmanuelle Noirrit
1   Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France
2   CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
4   I2MC, CHU de Toulouse and Université de Toulouse, Toulouse, France
› Author Affiliations

Abstract

Objective The study aimed to describe and to analyze the first morbidity and mortality review (MMRs) set up within a Dental University Hospital using detailed case reports to highlight the benefits of MMRs for patients, practitioners, teachers and to implement appropriate protocols to prevent recurrence.

Materials and Methods The MMRs were performed within the dentistry departments of the hospital over the 1-year study period. Each case was reviewed according to a protocol based on a tool defined by the Clinical Risk Unit and the Association of Litigation and Risk Management (ALARM).

Results Four cases were selected based on an oral report by a doctor from the dental service, a downstream service, or by the attending physician. The first case report related to a patient who suffered a breathing shock. The second concerned a tooth inhalation by a young disabled boy. The third was a therapeutic failure instigated by a student during a tooth preparation, and the fourth case involved an unexpected face-to-face meeting between a prisoner accompanied by police guards and an ancient victim at the dental hospital.

Discussion Clinical incidents were investigated with the ALARM protocol. This process is also less focused on the individual who makes the error and more on contributing systemic factors. The systematic analysis of cases associated with bibliographic reviews improves learning and performance outcomes. Clear answers were given in response to the problems raised during these MMRs.

Conclusion In dental hospitals, the culture of MMRs needs to be integrated into resident training like in medical hospitals.



Publication History

Article published online:
07 January 2021

© 2021. European Journal of Dentistry. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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