Association for Academic Surgery
Preventable mortality: does the perspective matter when determining preventability?

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Abstract

Background

We report a novel approach to mortality review using a 360° survey and a multidisciplinary mortality committee (MMC) to optimize efforts to improve inpatient care.

Methods

In 2009, a 16-item, 360° compulsory quality improvement survey was implemented for mortality review. Descriptive statistics were performed to compare the responses by provider specialty, profession, and level of training using the Fisher exact and chi-square tests, as appropriate. We compared the agreement between the MMC review and provider-reported classification regarding the preventability of each death using the Cohen kappa coefficient. A qualitative review of 360° information was performed to identify the quality opportunities.

Results

Completed surveys (n = 3095) were submitted for 1683 patients. The possibility of a preventable death was suggested in the 360° survey for 42 patients (1.40%). We identified 502 patients (29.83%) with completed 360° surveys who underwent MMC review. The inter-rater reliability between the provider opinions regarding preventable death and the MMC review was poor (kappa = 0.10, P < 0.001). Of the 42 cases identified by the 360° survey as preventable deaths, 15 underwent MMC review; 3 were classified as preventable and 12 were deemed unavoidable. Qualitative analyses of the 12 discrepancies did reveal quality issues; however, they were not deemed responsible for the patients' death.

Conclusions

The mortality survey yielded important information regarding inpatient deaths that historically was buried with the patient. Poor agreement between the 360° survey responses and an objective MMC review support the need to have a multipronged approach to evaluating inpatient mortality.

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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