Despite the importance of reducing inpatient mortality, little has been reported about establishing a hospitalwide, systematic process to review and address inpatient deaths. In 2006 the University of Pennsylvania Health System's Mortality Review Committee was established and charged with reducing inpatient mortality as measured by the mortality index--observed/expected mortality.
Between 2006 and 2012, through interdisciplinary meetings and analysis of administrative data and chart reviews, the Mortality Review Committee identified a number of opportunities for improvement in the quality of patient care. Several programmatic interventions, such as those aimed at improving sepsis and delirium recognition and management, were initiated through the committee.
During the committee's first six years of activity, the University HealthSystem Consortium (UHC) mortality index decreased from 1.08 to 0.53, with observed mortality decreasing from 2.45% to 1.62%. Interventions aimed at improving sepsis management implemented between 2007 and 2008 were associated with increases in severe sepsis survival from 40% to 56% and septic shock survival from 42% to 54%. The mortality index for sepsis decreased from 2.45 to 0.88. Efforts aimed at improving delirium management implemented between 2008 and 2009 were associated with an increase in the proportion of patients receiving a "timely" intervention from 18% to 57% and with a twofold increase in the percentage of patients discharged to home.
The establishment of a mortality review committee was associated with a significant reduction in the mortality index. Keys to success include interdisciplinary membership, partnerships with local providers, and a multipronged approach to identifying important clinical opportunities and to implementing effective interventions.
[Show abstract][Hide abstract] ABSTRACT: Background:
Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced.
Methods and findings:
The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement.
Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives.
PLoS Medicine 06/2014; 11(6):e1001667. DOI:10.1371/journal.pmed.1001667 · 14.43 Impact Factor
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