Aiming for zero preventable deaths: using death review to improve care and reduce harm

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Medical Error Analysis

Background:

• Organizations strive for zero preventable deaths, a goal requiring robust measurement and evaluation.
• Adverse events (AEs) and quality of care issues contribute to patient harm and mortality.
• A systematic approach is needed to identify, review, and mitigate factors leading to preventable deaths.

Purpose of the Study:

• To implement and evaluate an interdisciplinary Death and Adverse Event Review process.
• To establish a framework for identifying and reducing adverse events and quality of care issues.
• To support continuous improvement in patient care processes and progress toward zero preventable deaths.

Main Methods:

• Development of an interdisciplinary Death and Adverse Event Review process.
• Utilizing a modified Global Trigger Tool for initial chart review of patient deaths.
• Second-level review by a physician/interdisciplinary team for identified cases to recommend actions.

Main Results:

• Reviewed 1,817 deaths between 2008-2009, identifying AE rates of 12.1% and 16.3%.
• Identified 422 AEs and 114 quality of care issues, with 2.3%-2.6% leading to recommendations for improvement after secondary review.
• Initiated system-level improvements including documentation standards and guideline reviews.

Conclusions:

• The Death and Adverse Event Review process provides critical detail for improving care processes.
• This systematic review facilitates ongoing progress toward the goal of zero preventable deaths.
• The process effectively identifies actionable insights for both local and system-wide patient safety enhancements.