Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.
Approach to Improving Safety
- Discontinuities, Gaps, and Hand-Off Problems
- Medication Errors/Preventable Adverse Drug Events
- Nosocomial Infections
- Pressure Ulcers
- Surgical Complications
Setting of Care
This study reports on Kaiser Permanente's use of systems analysis approaches to review all cases of inpatient mortality, with the goal of identifying preventable harm.