title: Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.
abstract: OBJECTIVE
  Accurately and routinely identifying factors contributing to inpatient mortality remains challenging.
  
  
  OBJECTIVE
  To describe the development, implementation and performance of a new electronic mortality review method 1 year after implementation.
  
  
  METHODS
  An analysis of data gathered from an electronic instrument that queries front-line providers on their opinions on quality and safety related issues, including potential preventability, immediately after a patient's death. Comparison was also made with chart reviews and administrative data.
  
  
  RESULTS
  In the first 12 months, reviewers responded to 89% of reviews sent (2547 responses from 2869 requests), resulting in at least one review in 99% (1058/1068) of inpatient deaths. Clinicians provided suggestions for improvement in 7.7% (191/2491) of completed reviews, and reported that 4.8% (50/1052) of deaths may have been preventable. Quality and safety issues contributing to potentially preventable inpatient mortality included delays in obtaining or responding to tests (15/50, 30%), communication barriers (10/50, 20%) and healthcare associated infections (9/50, 18%). Independent, blinded chart review of a sample of clinician reviews detected potential preventability in 10% (2/20) of clinician reported cases as potentially preventable. Comparison with administrative data showed poor agreement on the identification of complications with neither source consistently identifying more complications.
  
  
  CONCLUSIONS
  Our early experience supports the feasibility and utility of an electronic tool to collect real-time clinical information related to inpatient deaths directly from front-line providers. Caregivers reported information that was complementary to data available from chart review and administrative sources in identifying potentially preventable deaths and informing quality improvement efforts.
authors.affiliation: Department of Medicine Residency Program, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Audrey
authors.initials: A
authors.lastname: Provenzano
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Shannon
authors.initials: S
authors.lastname: Rohan
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Elmy
authors.initials: E
authors.lastname: Trevejo
authors.affiliation: Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Burdick
authors.affiliation: Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.affiliation: Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Allen
authors.initials: A
authors.lastname: Kachalia
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data; D001291:Attitude of Health Personnel; D003144:Communication Barriers; D003428:Cross Infection / Q000453:epidemiology / Q000517:prevention & control; D017052:Hospital Mortality; D006801:Humans; D007256:Information Systems; D015279:Organizational Culture; D061214:Patient Safety / Q000706:statistics & numerical data*; D016730:Program Development; D058996:Quality Improvement / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D013997:Time Factors
keywords: Patient safety; Quality improvement; Quality improvement methodologies; Safety culture; Significant event analysis, critical incident review