Association for Academic SurgeryPreventable mortality: does the perspective matter when determining preventability?
Introduction
The Institute of Medicine report in 2000 [1], and subsequent reports in the media [2], [3], [4], [5], have publicized the notion that some patients die in the hospital as a result of medical errors. The heightened awareness of potentially preventable mortality has fueled the development of national initiatives [6], [7], [8] and regional [9], [10], institutional [6], [11], and departmental [12], [13] programs to address this critical issue in inpatient care [14]. These efforts have relied on risk-adjusted mortality rates [15] to account for differences in patient acuity across institutions [16], [17], [18] to successfully gauge the quality of care, as defined by the inpatient mortality measure.
Institutional efforts to reduce preventable mortality have included mortality and morbidity conferences and standardized mortality review. The time-honored departmental mortality and morbidity conference has often been limited by a lack of uniformity and structure [19], [20], [21]. Additionally, the nursing staff and other hospital personnel that contribute to the patients' clinical course are typically not present for these discussions [22], [23]. Alternatively, mortality review panels comprised of individuals and smaller groups of physicians have been noted to overestimate the preventable mortality and to possess a high degree of variability and error [24]. More recently, interdisciplinary mortality review committees, similar to those used by many trauma teams, have been implemented to investigate inpatient deaths within hospitals [12], [25], [26].
Although the systematic review of every inpatient death might provide invaluable information regarding opportunities for local and institutional improvement, these reviews are quite labor intensive and rely on the retrospective review of the clinical documentation. Information gathered from frontline providers based on the medical record has varied across specialties and is often difficult to interpret. Clinical documentation around critical events (i.e., adverse drug events) might not accurately capture the true nature of the occurrence, given the concerns regarding litigation [27].
We report a novel approach to gather real-time information about preventable inpatient mortality from all members of the clinical team using a hospital-wide 360° survey. Our report includes differences in provider responsiveness and opinions by service line and professional training.
Section snippets
Methods
The Hospital of the University of Pennsylvania is a 772-bed tertiary care hospital in eastern Pennsylvania. Approximately 41,000 admissions occur annually, with an annual mortality rate of 1.8%–2.0% during the past 5 years. In 2006, the Hospital of the University of Pennsylvania (HUP) formed a multidisciplinary mortality committee (MMC) to evaluate the quality of care delivered to patients who died during a hospitalization. After examination of the administrative data, detailed unstructured
360° Survey results and preventable mortality
During the study period, 2483 patients died within the hospital and 1683 patients had 360° surveys completed, for a response rate of 67.8%. Of the 3095 360° surveys completed for 1683 patients, 42 patient deaths (1.4%) were identified by the care providers as preventable. Of the patient deaths deemed preventable, most of the patients were men (54.8%) and white (57.1%). The mean age at death was 63.4 ± 16.9 y. Most patients with a preventable death identified by the providers had been emergently
Discussion
The electronic 360° mortality survey performed at a patient's death provides frontline caregivers with the opportunity to share information regarding the inpatient stay that would not be readily available by chart review or from the administrative claims data. In so doing, the hospital MMC is provided with a comprehensive view at inpatient deaths from the provider perspective in a format suitable for aggregated study providers to be able to contribute to quality improvement initiatives on
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Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement
2021, Journal of the American College of SurgeonsCitation Excerpt :Five studies also defined this as a data-driven identification of complications based on predefined criteria rather than voluntary report.2,4,6-8 Use of clinical registry or other predefined case criteria for case review input resulted in more adverse outcomes identified and more actionable items than traditional self-report case review processes.2,4,7 Adverse-event-centered case review (including morbidity or near misses) detected greater proportion of preventable events than mortality-centered case review.3
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2018, Joint Commission Journal on Quality and Patient SafetyCitation Excerpt :Ultimately, however, none of those deaths were deemed to have been preventable. This finding is consistent with prior research that showed only a fraction of deaths perceived to be preventable by health care professionals are actually deemed to have been preventable after detailed review.4,15,17 Despite this, each of the cases submitted for more review did reveal opportunities for improvement that would not otherwise have been identified, potentially helping to prevent future harm.
A 100% departmental mortality review improves observed-to-expected mortality ratios and University HealthSystem Consortium rankings
2014, Journal of the American College of SurgeonsThe mortality review committee: A novel and scalable approach to reducing inpatient mortality
2013, Joint Commission Journal on Quality and Patient SafetyCitation Excerpt :Gupta et al. reported that in a retrospective analysis of data from the The 360° survey data proved helpful in identifying actionable items for QI. Gupta et al. reported that in a retrospective analysis of data from the 3,095 360° surveys that the providers completed for 1,683 (67.8%) of the 2,483 patients who died at the hospital between February 2009 and March 2012, 1.40% (42 patients /3,095 surveys) of the deaths were recorded as preventable, with sepsis/infection (25.0%) a condition commonly associated with preventability.21 In addition, 26.2% of patients whose death was considered preventable experienced “early death,” defined as death within 48 hours of admission.21
Implementation of Hospital Mortality Reviews: A Systematic Review
2024, Journal of Patient Safety