Development of the ‘ People–Processes–Paradigm ’ critical analysis tool for mortality and morbidity reviews: improving understanding of systems factors

Background The impact of systems problems and human factors on delivering safe, high‐quality patient care is well recognized. In the surgical setting, mortality and morbidity reviews (MMRs) are the key forum for reviewing and analysing adverse events in patient care yet there is a paucity of simple tools for undertaking such analyses. The aim of this study was to develop and pilot a new tool for analysing mortality and morbidity cases...