Table 2

Care delivery opportunities illustrated by Brigham Mortality Review System and responses

Category	Case concerns identified Response
Care delay	Delay in blood delivery to the operating room (OR).	Retraining of OR staff in blood delivery. Evaluation of blood ‘Vending machine’ technology to facilitate more rapid delivery.
Care systems	Delay in labs during cardiac arrest in the OR.	Evaluation of strategies to improve lab turnaround time for intraoperative cases.
	Delay in lab samples led to delay in dialysis initiation.	Retrained lab staff about sample handling.
	Delay in paging responsible provider for patient code in radiology.	Unit staff trained to page appropriate personnel during code.
Clinical care	Aspiration of oral contrast before CT scan.	Developed aspiration flag within electronic health record (EHR) visible by transport and radiology. Transport and radiology reviewed with staff and implemented strategies to mitigate aspiration.
	Difficulty repositioning obese patient during code.	Reviewed case with lift team to prioritise rapid responses.
Clinical decision-making	Hyponatraemia after urologic procedure.	Urology case conference regarding hyponatraemia recognition and management.
	Patient with delirium pulled out left ventricular assist device cannula.	Delirium committee facilitated education sessions for intensive care unit staff.
Communication	Oncology consult delayed due to unclear paging directory.	Revised paging directory.
	Unclear patient code status.	Trained CT staff regarding reviewing code status in the EHR.
	Patient's clinical status deteriorated overnight, not communicated to attending.	Attending notification cards for house staff developed and distributed.
Diagnosis delay	Delay in reading CT scan by the attending overnight.	Paging directory allows for direct paging of attending.
Documentation	Medical Orders for Life-Sustaining Training (MOLST) form was not visible in EHR because it was not uploaded correctly.	Medical assistants retrained regarding uploading of MOLST forms.
End of life	Patient’s family requested pacemaker shutoff even though patient was pacemaker dependent.	Policy changed to reflect that the patient or healthcare proxy can request deactivation of devices such as pacemakers.
	Multiple cases regarding opportunities to improve goals of care discussions and documentation.	Multidisciplinary code committee established to discuss ongoing challenges. EHR changes to facilitate documentation. Hospital-wide education initiative regarding standardised content for code discussions.
Intravenous access	Difficulty obtaining intravenous access causing delays in care.	Evaluation of strategies to manage patients with difficult intravenous placements.
Medication error	Obese patient received enoxaparin underdose and had complication.	EHR alert reflecting special dosing requirements during ordering.
	Patient given suboptimal naloxone dose in setting of opiate overdose.	Emergency response committee edited algorithm regarding naloxone administration.
	Patient with prolonged QTc interval received QTc-prolonging medication.	EHR alert developed.
OSH transfer	Multiple safety issues with transfers from outside hospitals—including need for improved communication to front-line providers.	Multidisciplinary committee to address safety concerns. Nurse-led initiative to ensure all transfers have templated expect note. Piloting house staff notification process.
Staffing	Challenges with Arabic-speaking interpreter availability.	Centralizsed interpreter phone number. Additional Arabic-speaking interpreters hired.
Triage	Delay in intensive care unit (ICU) transfer due to discussion of cardiac versus medicine ICU.	Establishment of ICU policy based on primary diagnosis.

OSH, outside hospital.