Try the newly designed PSNet website! Learn More
PSNet: Patient Safety Network
Journal Article

Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.

Provenzano A, Rohan S, Trevejo E, et al. BMJ quality & safety. 2015;24:31-7.

Early efforts to characterize patient safety included the review of individual cases of patient deaths; mortality reviews remain a core aspect of hospital safety efforts. This study describes the implementation of an electronic tool which directly queries clinicians about specific cases of inpatient deaths. The authors determined that the tool was feasible to implement, and clinicians reported delays in accessing or responding to tests, communication barriers, and health care–associated infections as contributors to preventable inpatient mortality. When comparing clinician responses to administrative data, there was little agreement about the presence of complications, with neither source consistently identifying more complications. This work suggests that directly engaging with clinicians about inpatient mortality yields useful patient safety data beyond what chart review can provide and underscores the need to improve existing clinical documentation to support safety efforts.