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Anaesthetists and anaesthetic departments should report anesthesia-related death or illness, to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) within 28 days.

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.

What to report

  • 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

How to report

Mortality

This includes:

  • 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.
  1. Fill in the VCCAMM case report form (below)
  2. Submit to VCCAMM with the following information:
  • 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.

Morbidity

This includes 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.

  1. Fill in the VCCAMM case report form (below)
  2. Submit to VCCAMM with the following information:
  • 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, ASAP classification, elective or emergency status, location of event.

Downloads

Get in touch

VCCAMM
Safer Care Victoria
+61 3 9096 2729

Page last updated: 27 Jun 2018

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