PT  - JOURNAL ARTICLE
AU  - Kobewka, Daniel M
AU  - van Walraven, Carl
AU  - Turnbull, Jeffrey
AU  - Worthington, James
AU  - Calder, Lisa
AU  - Forster, Alan
TI  - Quality gaps identified through mortality review
AID  - 10.1136/bmjqs-2015-004735
DP  - 2017 Feb 01
TA  - BMJ Quality & Safety
PG  - 141--149
VI  - 26
IP  - 2
4099  - http://qualitysafety.bmj.com/content/26/2/141.short
4100  - http://qualitysafety.bmj.com/content/26/2/141.full
SO  - BMJ Qual Saf2017 Feb 01; 26
AB  - Background Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths.Objective To describe the implementation and results from an institution-wide mortality-review process.Design A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care.Results Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: ‘goals of care not discussed or the discussion was inadequate’ (n=25 (25.8%)) and ‘delay or failure to achieve a timely diagnosis’ (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings.Conclusions Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.