Learning From Every Death

Huddleston, Jeanne M.; Diedrich, Daniel A.; Kinsey, Gail C.; Enzler, Mark J.; Manning, Dennis M.

doi:10.1097/pts.0000000000000053

Cited by 33 publications

(43 citation statements)

References 4 publications

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“…Inadequate goals of care discussions were an identified opportunity for improvement, similar to our evaluation. The Mayo Clinic has adopted an approach with local physician and nurse leaders reviewing all deaths occurring from the area of the hospital providing care to the patient at the time of death, and conclude that adoption of their mortality review system has led to an increased focus on the culture of safety 17. The Hospital of the University of Pennsylvania implemented a real-time review system, similar to ours, in its querying of providers within 48 hours of death as an intervention trial over 1 year.…”

Section: Discussionmentioning

confidence: 99%

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

Mendu

Petersen

et al. 2019

BMJ Qual Saf

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ImportanceDeath due to preventable medical error is a leading cause of death, with varying estimates of preventable death rates (14%–56% of total deaths based on national extrapolated estimates, 3%–11% based on single-centre estimates). Yet, how best to reduce preventable mortality in hospitals remains unknown.ObjectiveIn this article, we detail lessons learnt from implementing a hospital-wide, automated, real-time, electronic mortality reporting system that relies on the opinions of front-line clinicians to identify opportunities for improvement. We also summarise data obtained regarding possible preventability, systems issues identified and addressed, and challenges with implementation. We outline our process of survey, evaluation, escalation and tracking of opportunities identified through the review process.MethodsWe aggregated and analysed 7 years of review data regarding deaths, review responses categorised by ratings of possible preventability and inter-rater reliability of possible preventability. A qualitative analysis of reviews was performed to identify care delivery opportunities and institutional response.ResultsOver the course of 7 years, 7856 inpatient deaths occurred, and 91% had at least one review completed. 5.2% were rated by front-line clinicians as potentially being preventable (likely or possibly), and this rate was consistent over time. However, there was only slight inter-rater agreement regarding potential preventability (Cohen’s kappa=0.185). Nevertheless, several major systems-level opportunities were identified that facilitated care delivery improvements, such as communication challenges, need for improved end-of-life care and interhospital transfer safety.ConclusionsThrough implementation, we found that a hospital-wide mortality review process that elicits feedback from front-line providers is feasible, and provides valuable insights regarding potential preventable mortality and prioritising actionable opportunities for care delivery improvements.

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Section: Discussionmentioning

confidence: 99%

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

Mendu

Petersen

et al. 2019

BMJ Qual Saf

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“…Several studies have reported improvements in patient safety following the presentation of cases at M&MCs and subsequent changes in patient care and management ( 12 , 13 , 22 , 25 , 26 , 29 , 30 ). A common theme of these reports is the clear structure to the M&MC process, though the degree and extent of standardization varied.…”

Section: Benefitsmentioning

confidence: 99%

“…A common theme of these reports is the clear structure to the M&MC process, though the degree and extent of standardization varied. Some studies focused on identifying and enacting mechanisms for improvement coupled with continuous monitoring of progress ( 12 , 13 , 20 , 25 , 29 ), while others focused on the care pathway ( 12 , 29 ), standardized presentation, and error analysis ( 12 , 13 ).…”

Section: Benefitsmentioning

confidence: 99%

“…These varied approaches have resulted in a 50% reduction in malpractice claims ( 20 ), improved safety culture and quality of care ( 20 , 25 , 29 , 30 ), and reductions in mortality of up to 40% ( 12 , 13 , 29 ). Data should be collected prospectively before as well as after implemented changes in management to properly establish the relationship between enacted changes and outcome.…”

Section: Benefitsmentioning

confidence: 99%

“…Cases should be presented and discussed soon after they occur. There is no evidence in support of a specific time frame, but early presentation reinforces the importance of timely acknowledgment of an adverse event ( 7 , 29 ). In large centers, the establishment of an M&M committee and coordinators facilitates efficient handling of reports and cases are typically presented within 4–8 weeks of reporting ( 19 , 24 , 29 ).…”

Section: Mandmc Formatmentioning

confidence: 99%

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Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine

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This mini review presents current knowledge on the role of morbidity and mortality conferences (M&MCs) as a powerful educational tool and driver to improve patient care. Although M&MCs have existed since the early twentieth century, formal evaluation of their impact on education and patient care is relatively recent. Over time, M&MCs have evolved from single discipline discussions with a tendency to focus on individual errors and assign blame, to multidisciplinary, standardized presentations incorporating error analysis techniques, and educational theory. Current evidence shows that M&MCs can provide a valuable educational experience and have the potential to generate measurable improvements in patient care.

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Learning From Every Death

Cited by 33 publications

References 4 publications

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

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

Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine

Resident Quality Training: More than Metrics

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