Since 2005, Mayo Clinic, Rochester, performs a formal multidisciplinary mortality review on all inpatient deaths. The vision of the Mortality Review System (MRS) is to eliminate suffering from process or systems of care failures. MRS is charged with identifying process and system failures that are opportunities to improve patient outcomes and reduce the mortality rate. Each inpatient death is independently reviewed by a nurse and physician using a mixed‐method process. Every patient story and all issues identified are recorded in a central registry and discussed in a large group multidisciplinary setting. The committee classifies any agreed‐upon issues into categories (delayed diagnosis, missed prophylaxis, etc.), and determines preventability of death using ACS guidelines. MRS findings are shared with relevant departments and hospital floors. We reviewed Mayo Clinic Rochester MRS data and compared the sensitivity of MRS to detect systems events as compared to other widely used adverse event detection systems.
We analyzed MRS review findings for all deaths occurring at Mayo Clinic Rochester during 2009 through Quarter 2 of 2013. These data were compared to events detected during the same time period using four different methodologies: NQF Serious Reportable Events (SRE, “never events”), Medicare Hospital Acquired Conditions (HAC), AHRQ Patient Safety Indicators (PSI), and Adverse Events reported to the State of MN. Events detected using all 5 methodologies were not necessarily implicated as a cause or even a contributor to the patient’s death.
Among inpatients of the 2 hospitals during this period, there were 4460 deaths (average of 991 deaths/year). 1890 (42.4%) of deaths occurred among patients initially admitted to an ICU, whereas 2062 deaths (46.2%) occurred in an ICU. 516 (11.6%) non‐ICU deaths occurred in patients admitted to a surgical service. 1048 (23.5%) deaths occurred in patients documented as Do Not Resuscitate at the time of death. MRS identified at least 1 opportunity for improvement in 522 deaths (11.7%). Of these, 159 (3.6% of all deaths) were classified as unanticipated. A total of 1236 systems issues were identified among inpatients that died during this period (average of 0.28 issues/death). The systems issues most frequently identified by MRS were those related to delayed or inadequate escalation of care or resuscitation (378 [26.8%]), incorrect or delayed diagnosis (243 [17.2%]), and inadequate communication/documentation (206 [14.6%]). Among inpatient deaths, MRS detected more adverse events than would be detected by NQF SRE, Medicare HAC, AHRQ PSI, or MN Adverse Event Reporting.
The Mayo Clinic MRS program is successful at identifying systems issues occurring among patients who die while admitted. We believe that the increased sensitivity of MRS over other commonly employed methodologies detects more systems events and is more useful for creating meaningful improvement interventions.
To cite this abstract:Jones J, Huddleston J. Every Inpatient Death Creates an Opportunity to Save Lives: The Mayo Clinic Mortality Review System. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 80. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/every-inpatient-death-creates-an-opportunity-to-save-lives-the-mayo-clinic-mortality-review-system/. Accessed May 23, 2019.