@article{4138,
  keywords = {Patient safety, Quality improvement, Quality improvement methodologies, Safety culture, Significant event analysis, critical incident review},
  author = {Audrey Provenzano and Shannon Rohan and Elmy Trevejo and Elisabeth Burdick and Stuart Lipsitz and Allen Kachalia},
  title = {Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.},
  abstract = {<p><b>IMPORTANCE: </b>Accurately and routinely identifying factors contributing to inpatient mortality remains challenging.</p><p><b>OBJECTIVE: </b>To describe the development, implementation and performance of a new electronic mortality review method 1 year after implementation.</p><p><b>METHODS: </b>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.</p><p><b>RESULTS: </b>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.</p><p><b>CONCLUSIONS: </b>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.</p>},
  year = {2015},
  journal = {BMJ Qual Saf},
  volume = {24},
  pages = {31-7},
  month = {01/2015},
  issn = {2044-5423},
  doi = {10.1136/bmjqs-2014-003120},
  language = {eng},
}