title: E-Autopsy: Using Structured Hybrid Manual/Electronic Mortality Reviews to Identify Quality Improvement Opportunities.
abstract: BACKGROUND
  Mortality reviews are a foundation of inpatient quality improvement (QI), but low levels of harm among a random or sequential sample may not yield actionable improvement opportunities. To increase the efficiency of mortality reviews at identifying QI opportunities, Kaiser Permanente Southern California (KPSC) developed a condition-specific hybrid electronic/manual chart review called the "e-autopsy."
  
  
  METHODS
  KPSC hospital deaths are filtered electronically by predetermined criteria. Teams consisting of a registered nurse and physician trained in QI at each hospital then manually review selected charts using a structured data-extraction tool to identify gaps in provision of evidence-based care. Results are aggregated and studied to identify improvement opportunities.
  
  
  RESULTS
  E-autopsy has identified opportunities amenable to system improvements. The first e-autopsy of all KPSC members who died with a ruptured abdominal aortic aneurysm (AAA) in a KPSC hospital indicated that many patients meeting criteria had not been screened for AAA. This study showed KPSC leaders the value of point-of-care electronic decision support to increase evidence-based AAA screening and of a tracking system for patients with positive results. Screening among high-risk patients in 2012 increased by more than 8,000 individuals, compared with the annual average during the previous four years. E-autopsies have also been conducted of patients who died with aspiration pneumonia; after unplanned transfers to the ICU; and after diagnosis of colon cancer.
  
  
  CONCLUSIONS
  E-autopsy reveals actionable opportunities to improve care systems, complementing other QI activities. This hybrid electronic/manual process can be applied to a wide variety of patient conditions and settings.
authors.affiliation: Department of Quality and Performance Improvement, Kaiser Permanente Southern California, Fontana, California. USA.
authors.forename: Kerry C
authors.initials: KC
authors.lastname: Litman
authors.forename: Helen
authors.initials: H
authors.lastname: Lau
authors.forename: Michael H
authors.initials: MH
authors.lastname: Kanter
authors.forename: Jason P
authors.initials: JP
authors.lastname: Jones