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Resume Objectifs Les objectifs principaux etaient la description des modalites de fonctionnement des revues de la mortalite morbidite (RMM), l’analyse des causes de deces evitables ou de complications graves, ainsi que l’elaboration de themes d’actions a mettre en œuvre afin d’eviter que l’evenement indesirable ne se reproduise. Methodes Nous avons mis en place un comite de coordination des RMM constitue d’un representant de chaque specialite exercee au sein de notre etablissement. Chaque representant etait charge d’organiser des reunions de service au cours desquelles le cas de patients ayant eu une complication grave ou dont le deces etait potentiellement evitable etait analyse. Resultats Le comite de coordination des RMM de l’etablissement s’est reuni 3 fois par an afin d’ameliorer la methodologie de l’analyse des dossiers patients. Au sein de chaque service, une frequence moyenne de 3 reunions par an a ete observee (1 a 12 pour les valeurs extremes), aux cours desquelles 1 a 3 dossiers ont ete analyses. Au cours d’une periode de 30 mois d’activite, parmi les 35 817 patients admis a l’institut, 341 (1%) sont decedes. Le taux de deces evitable variait selon les departements (mediane 27%, extremes de 6 a 65%). Parmi les patients analyses en RMM (n = 92, 27 % ; extremes de 6 a 70 % des deces hospitaliers selon les services), un taux important d’infections nosocomiales (30%) a ete note. La pathologie la plus frequente a l’origine des deces inattendus a ete la pathologie cardiaque. Discussion Les ameliorations principales a apporter ont concerne la strategie medicochirurgicale, la technique operatoire, le respect des indications lors des prescriptions medicamenteuses et la surveillance du patient.

The objective of this study was to describe the steps involved in establishing a morbidity/mortality review committee (MMRC) to analyze the causes of avoidable deaths or life-threatening complications and the development of plans and protocols to avoid their recurrence.The MMRC included physicians from each hospital department. Each member was responsible for organizing departmental meetings to analyze its avoidable deaths and life-threatening complications.During its meetings three times a year, the MMRC developed a method for analysis of these serious events. Each department organized 3 (range: 1-12) meetings a year and analyzed 1-3 cases at each. Over 30 months, 35,817 patients were admitted to the hospital and 341 (1%) died. The unexpected mortality rate varied by department and specialty (median: 27%, range: 6-65%). In all, 92 cases were referred to MMRC meetings (27%; range: 6-70% of hospital deaths), and 30% of them involvement nosocomial diseases. Heart disease was the primary cause of unexpected deaths.The principal improvements involved medical and surgical strategies, surgical techniques, drug prescriptions, and patient monitoring.