Importance Accurately and routinely identifying factors contributing to inpatient mortality remains challenging.
Objective To describe the development, implementation and performance of a new electronic mortality review method 1 year after implementation.
Methods An analysis of data gathered from an electronic instrument that queries front-line providers on their opinions on quality and safety related issues, including potential preventability, immediately after a patient's death. Comparison was also made with chart reviews and administrative data.
Results In the first 12 months, reviewers responded to 89% of reviews sent (2547 responses from 2869 requests), resulting in at least one review in 99% (1058/1068) of inpatient deaths. Clinicians provided suggestions for improvement in 7.7% (191/2491) of completed reviews, and reported that 4.8% (50/1052) of deaths may have been preventable. Quality and safety issues contributing to potentially preventable inpatient mortality included delays in obtaining or responding to tests (15/50, 30%), communication barriers (10/50, 20%) and healthcare associated infections (9/50, 18%).
Independent, blinded chart review of a sample of clinician reviews detected potential preventability in 10% (2/20) of clinician reported cases as potentially preventable. Comparison with administrative data showed poor agreement on the identification of complications with neither source consistently identifying more complications.
Conclusions Our early experience supports the feasibility and utility of an electronic tool to collect real-time clinical information related to inpatient deaths directly from front-line providers. Caregivers reported information that was complementary to data available from chart review and administrative sources in identifying potentially preventable deaths and informing quality improvement efforts.
- Patient safety
- Quality improvement
- Quality improvement methodologies
- Safety culture
- Significant event analysis, critical incident review
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