Table 1

Developing the mortality review process—consensus design principles

InfrastructureData collection must be electronic
ReportingData should be aggregated and trended across all departments
ScopeProcess must cover all deaths
SourceFront-line clinician input can provide more information than a centralised process (3rd party clinician review): must eventually include entire care team (eg, attendings, residents, nurses)
SpeedReview must be quick and efficient (many deaths not preventable)
TimingReviews should be completed within 48–72 h after the death (allow completion from memory without additional chart review)
Additional reviewSome cases may require further inquiry or may need to be reviewed by other departments