title: Quality gaps identified through mortality review.
abstract: Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths.
  
  
  
  To describe the implementation and results from an institution-wide mortality-review process.
  
  
  
  A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care.
  
  
  
  Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: 'goals of care not discussed or the discussion was inadequate' (n=25 (25.8%)) and 'delay or failure to achieve a timely diagnosis' (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings.
  
  
  
  Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.
authors: Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.|Department of Epidemiology and Community Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
authors: Daniel M
authors: DM
authors: Kobewka
authors: Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors: Carl
authors: C
authors: van Walraven
authors: The Ottawa Hospital, Ottawa, Ontario, Canada.
authors: Jeffrey
authors: J
authors: Turnbull
authors: The Ottawa Hospital, Ottawa, Ontario, Canada.
authors: James
authors: J
authors: Worthington
authors: Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.|Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors: Lisa
authors: L
authors: Calder
authors: Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.|Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors: Alan
authors: A
authors: Forster
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002170:Canada / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008875:Middle Aged; D009096:Multi-Institutional Systems; D011787:Quality of Health Care / Q000592:standards*
keywords: Chart review methodologies; Healthcare quality improvement; Hospital medicine; Quality measurement