Victorian Consultative Council on Anaesthetic Mortality and Morbidity

Reporting information

Page contents: Reporting to VCCAMM | Confidential Report Form | Suggested List for Reporting to VCCAMM | Anaesthesia-related mortality | Anaesthesia-related morbidity

Reporting to VCCAMM

The Council’s ability to monitor, analyse and report on anaesthesia-related adverse events is based on the voluntary submission of direct reports from treating anaesthetists, or indirect reports from other medical practitioners or hospital anaesthetic departments through their quality assurance processes. These reports are submitted via the 'Confidential Report' form.

Confidential Report Form

 Confidential Report - Initial Report

Suggested List for Reporting to VCCAMM

From 1 January 2010, under Section 39 of the Public Health and Wellbeing Act 2008, VCCAMM may issue a notice requesting the provision of general or specific information on anaesthesia related mortality and morbidity adverse events from all Victorian Hospitals and Pathology Services.
Suggested cases to be reported to VCCAMM are inclusive of but not restricted to the following:

• Mortality or morbidity resulting from inadequate pre-operative assessment and/or management
• Adverse events arising from problems in management of the airway or ventilation
• Unexpected cardiac arrest or other circulatory problems occurring in the peri-operative period
• Peri-operative myocardial infarction occurring within 72 hours of anaesthesia
• All neurological complications
• All drug related complications including adverse reactions, interactions and administration errors
• Problems associated with monitoring including inadequate provision and/or complications
• Problems associated with inadequate crisis management and/or resuscitation
• Problems associated with peri-operative pain management
• Significant equipment related problems
• Awareness during anaesthesia
• Mortality or morbidity associated with anaesthesia or sedation for investigational procedures or resuscitation
• Anaesthesia-related procedural errors
• Adverse events attributable to organisational problems associated with anaesthesia and/or perioperative care.

Anaesthesia-related mortality

The Council defines anaesthesia-related mortality as

• a death which occurs during an operation or procedure (or within 24 hours of its completion) performed with the assistance of sedative, analgesic, local or general anaesthetic drugs or any combination of these

or

• a death which may be the result (either partially or totally) of an incident during or after such operation or procedure even if more than 24 hours have elapsed since its completion.

In the event of an anaesthesia-related death, the following information is to be forwarded to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity within 28 days of the death:

• The anaesthesia record
• The preoperative assessment including:
  • medical co-morbidities
  • previous surgical history
  • list of current medications
  • relevant investigations
  • airway or other anaesthesia issues
  • any other case specific details;
• the operation or procedure report;
• a summary of postoperative events, including ICU/HDU if relevant;
• any relevant postoperative investigations;
• a copy of the eMedical deposition to the coroner if applicable;
• any other specifically relevant data and/or documents, including age, gender, ASA–P classification, elective or emergency status, location of event leading to death, location of death.

Anaesthesia-related morbidity

The Council defines anaesthesia-related morbidity as any event related to an anaesthetic procedure which causes a life-threatening incident, temporary or permanent disability or significant distress. Morbidity is categorised as major or minor according to outcome.

In the event of an anaesthesia-related morbidity, the following information is to be forwarded to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity within 28 days of the adverse event:

• the anaesthesia record;
• the preoperative assessment including:
  • medical co-morbidities
  • previous surgical history
  • list of current medications
  • relevant investigations
  • airway or other anaesthesia issues
  • any other case specific details
• the operation or procedure report
• a summary of postoperative events, including ICU/HDU if relevant
• any relevant postoperative investigations
• details of the clinical outcome from the adverse event
• any other specifically relevant data and/or documents, including age, gender, ASA–P classification, elective or emergency status, location of event.

We expect that electronic reporting will re-commence in late 2012.

In the meantime, please send the completed Confidential Report and supporting documentation to:

The Chairman
VCCAMM
GPO Box 4923
Melbourne VIC 8060

Or email: vccamm@health.vic.gov.au