Document Detail

Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.
MedLine Citation:
PMID:  25332203     Owner:  NLM     Status:  Publisher    
IMPORTANCE: Accurately and routinely identifying factors contributing to inpatient mortality remains challenging.
OBJECTIVE: To describe the development, implementation and performance of a new electronic mortality review method 1 year after implementation.
METHODS: An analysis of data gathered from an electronic instrument that queries front-line providers on their opinions on quality and safety related issues, including potential preventability, immediately after a patient's death. Comparison was also made with chart reviews and administrative data.
RESULTS: In the first 12 months, reviewers responded to 89% of reviews sent (2547 responses from 2869 requests), resulting in at least one review in 99% (1058/1068) of inpatient deaths. Clinicians provided suggestions for improvement in 7.7% (191/2491) of completed reviews, and reported that 4.8% (50/1052) of deaths may have been preventable. Quality and safety issues contributing to potentially preventable inpatient mortality included delays in obtaining or responding to tests (15/50, 30%), communication barriers (10/50, 20%) and healthcare associated infections (9/50, 18%). Independent, blinded chart review of a sample of clinician reviews detected potential preventability in 10% (2/20) of clinician reported cases as potentially preventable. Comparison with administrative data showed poor agreement on the identification of complications with neither source consistently identifying more complications.
CONCLUSIONS: Our early experience supports the feasibility and utility of an electronic tool to collect real-time clinical information related to inpatient deaths directly from front-line providers. Caregivers reported information that was complementary to data available from chart review and administrative sources in identifying potentially preventable deaths and informing quality improvement efforts.
Audrey Provenzano; Shannon Rohan; Elmy Trevejo; Elisabeth Burdick; Stuart Lipsitz; Allen Kachalia
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2014-10-20
Journal Detail:
Title:  BMJ quality & safety     Volume:  -     ISSN:  2044-5423     ISO Abbreviation:  BMJ Qual Saf     Publication Date:  2014 Oct 
Date Detail:
Created Date:  2014-10-21     Completed Date:  -     Revised Date:  2014-10-22    
Medline Journal Info:
Nlm Unique ID:  101546984     Medline TA:  BMJ Qual Saf     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Copyright Information:
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
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