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PSNet: Patient Safety Network
Journal Article

Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning.

Lucier D, Folcarelli P, Totte C, et al. Joint Commission journal on quality and patient safety. 2018;44:84-93.

Mortality reviews, in which all cases of in-hospital death are discussed in structured format, can detect patient safety problems. This study reports the results of a mortality review survey in hospital medicine and intensive care units at an academic medical center. The survey aimed to identify deaths that merited further investigation. Researchers identified five deaths that would not have come to light through other hospital case review mechanisms. Respondents expressed needs for both clinician support following patient deaths and greater advance care planning. The authors conclude that frontline care team surveys can augment existing hospital mortality review processes. Previous WebM&M commentaries have highlighted the importance of advance care planning, particularly for seriously ill older patients and those with advanced dementia.