Department of Health

Reporting to VCCAMM

Key messages

  • The Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM)receives reports of anaesthesia-related deaths and illnesses that are submitted voluntarily by anaesthetists and anaesthetic departments.
  • VCCAMM may formally request information on an anaesthesia-related mortality or morbidity case from a hospital or pathology service.
  • In the event of an anaesthesia-related death or morbidity, a detailed list of documentation is to be forwarded to VCCAMM within 28 days.

Statewide monitoring and reporting of anaesthesia-related mortality and morbidity by the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) is based on the voluntary submission of direct reports from treating anaesthetists, or indirect reports from other medical practitioners or hospital anaesthetic departments.

All reports are submitted electronically through VCCAMM’s confidential case-reporting form.To submit a case report, please click on the link below:

VCCAMM confidential case-reporting form

What to report to VCCAMM

Under the Public Health and Wellbeing Act 2008, VCCAMM may issue a notice requesting general or specific information on any anaesthesia-related mortality or morbidity case from a Victorian hospital or pathology service.

Cases that should be reported to VCCAMM include:

  • mortality or morbidity resulting from inadequate preoperative 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 perioperative period
  • perioperative 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 perioperative 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.

The council defines ‘anaesthesia-related mortality’ as one of the following:

  • a death that 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
  • a death that may result (either partially or totally) from an incident during or after such an 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 should be forwarded to VCCAMM within 28 days of the death:

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

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

In the event of an anaesthesia-related morbidity, the following information should be forwarded to VCCAMM within 28 days of the adverse event:

  • the anaesthesia record
  • the preoperative assessment, including medical comorbidities, previous surgical history, current medications, investigations, airway or other anaesthesia issues, etc.
  • the operation or procedure report
  • a summary of post-operative events, including the intensive care unit or high-dependency unit if relevant
  • any relevant post-operative investigations
  • details of the clinical outcome from the adverse event
  • any other relevant data and/or documents, including age, gender, ASA-P classification, elective or emergency status, location of event.

Reviewed 05 October 2015

Health.vic

Contact details

Victorian Consultative Council on Anaesthetic Mortality and Morbidity Safer Care Victoria

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