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Quality gaps identified through mortality review
  1. Daniel M Kobewka1,2,
  2. Carl van Walraven1,3,
  3. Jeffrey Turnbull4,
  4. James Worthington4,
  5. Lisa Calder5,6,
  6. Alan Forster1,6
  1. 1Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
  2. 2Department of Epidemiology and Community Medicine, The University of Ottawa, Ottawa, Ontario, Canada
  3. 3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  4. 4The Ottawa Hospital, Ottawa, Ontario, Canada
  5. 5Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
  6. 6Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  1. Correspondence to Dr Daniel Michael Kobewka, Department of Medicine, The Ottawa Hospital, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada; dkobewka{at}


Background Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths.

Objective To describe the implementation and results from an institution-wide mortality-review process.

Design A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care.

Results Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: ‘goals of care not discussed or the discussion was inadequate’ (n=25 (25.8%)) and ‘delay or failure to achieve a timely diagnosis’ (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings.

Conclusions Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.

  • Chart review methodologies
  • Hospital medicine
  • Healthcare quality improvement
  • Quality measurement

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  • Contributors DMK contributed to data acquisition, analysis and interpretation. He also drafted the article. CvW participated in data analysis, interpretation and critical appraisal of the manuscript. JT participated in project design, interpretation of data and critical appraisal of the manuscript. JW participated in interpretation of data and critical appraisal of the manuscript. LC participated in project design, data acquisition and interpretation of data. She also critical appraised the manuscript for intellectual content. AF designed the project, performed data acquisition, analysis and interpretation. He also critically appraised and revised the manuscript.

  • Funding The Ottawa Hospital Academic Medical Organization.

  • Competing interests None declared.

  • Ethics approval The Ottawa Hospital Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Forms used for data collection and chart review are available from DMK ( on request.