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PSNet: Patient Safety Network
Journal Article
Study

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

Mendu ML, Lu Y, Petersen A, et al. BMJ Quality & Safety. 2020;29.

This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.