Causes of Unexpected Deaths on Inpatient Medical Services at an Academic Medical Center — Are Some Cases Avoidable?

1Hospital of the University of Pennsylvania, Philadelphia, PA
2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 216


Mortality in healthcare is the most unambiguous clinical outcome. Academic medical centers are ranked on the observed to expected mortality ratio developed by the University Healthcare Consortium (UHC). Emphasis on expected deaths, however, creates an incentive for hospitals to focus on post‐mortem coding and perpetuate a perception that these deaths are inevitable. Many people in hospitals, however, die unexpectedly. Understanding the causes of unexpected deaths could give administrators an impetus to shift away from a focus on coding. This study evaluates the causes of unexpected deaths occurring on inpatient medical services at a large academic medical center.


We initially reviewed 58 deaths of patients considered “low risk” by UHC data from 2012. Due to an observed disparity between UHC code of “low risk” and actual clinical risk factors in these patients, we subsequently conducted an observational quality‐improvement study by reviewing all deaths (N = 101) taking place during a four‐month period in 2013. Data was collected via chart reviews by an Internal Medicine resident within several days to 8 weeks of time of death. When necessary, the care team was contacted for clarifying information. Our initial analysis indicated that aspiration was a significant cause of unexpected decompensations and death. Multiple risk factors for aspiration were therefore evaluated using Fisher’s exact test.


Among the 58 deaths characterized as UHC code of “low risk” in 2012, most were found to have advanced underlying disease. Of the 58 deaths, only nine (15%) deaths were unexpected 24 hours prior to occurrence. We found that 11 (19%) out of the 58 deaths were aspiration related. Among the 101 consecutive deaths subsequently reviewed in 2013, 54 (54%) patients had an unexpected decompensation leading to escalation of care and/or death. Of the 101 cases, 23 (23%) deaths were considered unexpected 24 hours earlier and 19 (19%) were due to aspiration. Sepsis unrelated to aspiration pneumonia was the second most common cause of unexpected decompensation, occuring in 11 cases. Aspiration accounted for 39% (9 of 23) of deaths that were unexpected 24 hours prior. Patients who aspirated were significantly more likely to have impaired consciousness, history of aspiration pneumonia, positive swallow screen/evaluation, profound deconditioning, or history of dysphagia (p<0.05).


We found that a large percentage of deaths were unexpected up to 24 hours prior to time of death and identified aspiration as a common proximal cause. Of the risk factors that contributed to aspiration, impaired level of consciousness was the most significant in our population. Based on this study, we are implementing an aspiration tool at our institution to reduce preventable inpatient deaths. In addition, we have found several other opportunities for improvements in provision of care and end‐of‐life decision‐making. Our study shows that by focusing on the clinical details surrounding inpatient deaths, rather than on coding data, we can identify new areas for focused quality improvement. Evaluating cases as they occur allows for better identification of potential interventions to reduce inpatient mortality.

To cite this abstract:

Gitelman Y, Qamar M, Ge J, Shannon R. Causes of Unexpected Deaths on Inpatient Medical Services at an Academic Medical Center — Are Some Cases Avoidable?. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 216. Journal of Hospital Medicine. 2014; 9 (suppl 2). Accessed April 1, 2020.

« Back to Hospital Medicine 2014, March 24-27, Las Vegas, Nev.