It is known that 60% of American patients die in the hospital. As our population ages and technology advances, in‐patient management becomes more complex in the hospital. It is unknown how much of inpatient mortality and nosocomial morbidity is related to our complex health care delivery systems.
The Mayo Clinic Hospital leadership recognized the gap in understanding morbidity and mortality in our complex health care delivery setting. They convened a core multidisciplinary team charged to: (1) create a meaningful mechanism to review death (thorough understanding, measurable and improvable); (2) identify and quantify unanticipated and nosocomial deaths; (3) identify rates of adverse events in patients who die; and (4) classify and quantify system‐level changes necessary to decrease mortality. This mortality review subcommittee's primary vision became that no person would suffer or die as a result of systems and/or operations failure.
A multidisciplinary and multispecialty team of more than 40 people developed a process to review every death in our institution (5 hospitals) from October 1, 2006, to September 30, 2007. Every death is reviewed by 1 nurse (within 72 hours of death) and then assigned to at least 1 physician and 1 nurse for formal review. Physician assignment is based on medical specialty. Each death is classified by the physician reviewer as definitely preventable, possibly preventable (<50/50 chance), probably preventable (>50/50 chance), not preventable, or not preventable but with systems issues. If a systems issue is identified, the case is referred on to a second independent reviewer. Cases identified with some element of system issues are presented and discussed at monthly all‐member committee meetings. One hundred percent consensus is required to ultimately label any death as having some degree of preventability.
One thousand and fifty deaths were reviewed. An average of 20 deaths occurred per week. Eight‐seven deaths per month (ranging from 70 to 107 deaths/month). Deaths were distributed among departments as follows: 63%, department of medicine; 16%, surgical departments; and 21%, medical specialties. The most common systems or nosocomial issues identified were aspiration pneumonia, hypoglycemia in nondiabetics, narcotic‐induced respiratory depression, failure to recognize septic and hypovolemic shock, anticoagulation‐associated bleeds and failure to rescue. As a result of what we learned, the institution funded 2 multidiscipli‐nary initiatives (aspiration prevention and septic shock recognition). Some cases were also used to provide data for established quality groups and departmental morbidity and mortality conferences. Future steps will include: (1) enhancing reporting mechanisms to all practice areas, (2) enhancing transparency of lessons learned to all levels of care providers, and (3) increasing scholarship.
J. Huddleston, none; K. Casey, none; M. Enzler, none.
To cite this abstract:Casey K, Huddleston J, Enzler M. Mortality Review. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 89. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/mortality-review/. Accessed March 20, 2019.