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Based on a review of the minutes of the Surgical Tissue and Audit Committee of Maine General Medical Center, from January 2010 through November 2010, along with interviews with the Chief Medical Officer at the time of the survey, it was determined that the Maine General Medical Center ' s Surgical Staff did not conduct reviews of adverse outcomes that would adequately identify the causes of the adverse outcome, nor provide learning throughout the hospital.

Findings include:

1. The Surgical Tissue and Audit Committee performed case reviews of surgical complications. Minutes reflect a committee at the Waterville Campus and a different committee at the Augusta Campus.

2. According to these minutes, there were no joint meetings of these committees, and Surgeons who operate at both locations have their cases reviewed by the committee at the Campus where the operation occurred.

3. Cases reviewed by the committees are assigned a score of " Grade 0, (management appropriate), Grade 1, (complications occurred which is a recognized risk of the operation), or Grade 2, (management inappropriate). The meeting minutes at the Augusta Campus provide a case summary of the entire hospital course. The Waterville Campus case summaries provide only a description of the surgical care. The Chief Medical Officer in a meeting on December 9, 2010 confirmed the difference in detail of the minutes.

4. In the Augusta Campus minutes, seven (7), cases were judged to be " Grade 2 " , (management inappropriate). Responses were sought from the surgeons in these seven (7), cases. There were four (4) cases described as being Grade 2 in the Waterville minutes. No responses were sought from any of the Waterville cases according to the letters attached to the minutes.

5. These minutes reflected that one of the Augusta Grade 2 cases was re-reviewed after a response from the surgeon and the care was then judged to be appropriate. For the remaining six (6), Grade 2 cases from Augusta, or four (4) Grade 2 cases from Waterville, there is no evidence to reflect that the committee received a response from the surgeon.

6. During an interview on December 9, 2010, the Chief Medical Officer agreed that the minutes do not reflect responses from Surgeons as requested. He said that the response to the committee chair may be verbal and not documented, but agreed there is no record that this happens, and the minutes do not reflect verbal responses.

7. The Augusta minutes describe non-surgical complications, but there is no evidence that the complications were referred to, or discussed by, the involved medical specialties. During an interview on December 9, 2010, the Chief Medical Officer agreed that there was no organized method to review cases between medical specialties. He also agreed that the Waterville minutes did not contain sufficient detail to determine the involvement of other medical specialties in the care of the patients.

8. During an interview on December 9, 2010, the Chief Medical Officer stated that Maine General Medical Center should develop a method to identify cases where complications appear to cross medical specialties, and suggested that a " root cause analysis " of these complications would be appropriate.