Quality gaps identified through mortality review.
BMJ Qual Saf. 2016 Feb 8;
Authors: Kobewka DM, van Walraven C, Turnbull J, Worthington J, Calder L, Forster A
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.
PMID: 26856617 [PubMed - as supplied by publisher]