Aiming for Zero Preventable Deaths: Using Death Review to Improve Care and Reduce Harm

Abstract

In 2005, our organization set a goal of zero preventable deaths by 2010 -notionally a sound goal but extremely challenging to measure, monitor and evaluate. The development of an interdisciplinary Death and Adverse Event Review process has provided a measure and framework for action to decrease adverse events (AEs) that cause harm.Death and Adverse Event Review is a formal process in which trained reviewers consider patient deaths using a modified Global Trigger Tool to establish the presence of AEs or quality of care issues that may have potentially led to death or harm. When identified, these charts go to second-level review by a physician/interdisciplinary team to determine recommendations for actions to prevent future reoccurrences. Data have provided trending of system influences to patient safety. In 2008-2009, 1,817 deaths were reviewed and AE rates of 12.1% and 16.3% were identified. There were 422 AEs and 114 quality of care issues identified for follow-up. Of the 4.7% and 6.3% referred to the physician/interdisciplinary team for secondary review, 2.3% and 2.6% resulted in recommendations for improvement. In addition to local improvements, many system improvements have occurred as a result of the review, such as proposed minimum standards for physician documentation; a formal review of post-operative guidelines for patients with sleep apnea; and a working group to review nursing documentation, communication/follow-up of vital signs, fluid balance and pain management. The Death and Adverse Event Review process provides a new critical level of detail that supports continuous improvements to our care processes and ongoing progress toward our goal of zero preventable deaths.

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt

“…Most previously published mortality review implementation studies describe retrospective reviews conducted by nurses and physicians of a random sample of hospital deaths 4–6. Other institutions detail a comprehensive retrospective review using trained patient safety specialist reviewers 7. Department-specific morbidity and mortality conferences are often used to review select cases 8 9.…”

“…A range of strategies have been employed to improve the recognition of medical errors that result in death 4–16. Most published US mortality review studies do not incorporate front-line providers—a crucial source of information that is often underappreciated—to identify potential errors.…”

Medical morbidity and mortality conferences: past, present and future

“…This enabled the hospitals to design subsequent improvement projects. In the second study in Canada, 1817 deaths were reviewed and adverse event rates of 12.1% and 16.3% were found for 2008 and 2009 14. Analysis of these events led to approximately 20 recommendations for improvement each year.…”

The Harvard medical practice study trigger system performance in deceased patients

“…However, the literature shows that the most important AEs and more hints for possible improvement of care in all patients appear in deceased patients [14–17]. Moreover, several studies have shown higher numbers of preventability of AEs in this subgroup [2, 12, 14, 18]. Thus, apart from optimizing the trigger tool itself, using it in this sample of patients might increase the performance and lower the burden of scrutinizing records without possible preventable AEs [19].…”