Multi-professional mortality review: supporting a culture of teamwork in the absence of error finding and blame-placing.

Commitment to patient safety must be a priority of every healthcare institution. York Central Hospital has implemented a quality initiative to address multi-professional issues that result from a significant sentinel event where there is a notion of perceived wrongdoing due to an adverse and/or unexpected outcome--the Multi-Professional Mortality Review process. Unlike the traditional approach to professional review in healthcare, which results in a culture of error finding and blame-placing, this process acknowledges the fact that human errors can occur, reaffirms what is working well and ensures that steps are taken to mitigate the effects of the sentinel event under consideration. The review panel consists of healthcare professionals who have been involved in the case. The panel reviews the case and makes recommendations to senior clinical committees and hospital administration. The multi-professional review process has been met with a positive response at York Central Hospital and, to date, has served as a driving force behind the implementation of a number of systemic and professional changes.