Development and Implementation of an Inpatient Mortality Review: a Feasibility Study

Hospital-wide mortality review processes are increasingly used to analyze inpatient deaths and identify opportunities to improve patient safety. This study evaluated the feasibility of developing and implementing such a mortality review in a German academic medical center.

We developed a mortality review checklist based on the Harvard Mortality Review and conducted a pilot test to assess its usability and integration into clinical systems (stage 1). Findings from the pilot phase informed revisions to the checklist and review processes. The adapted checklist was then implemented hospital-wide over 12 months (stage 2). Implementation was evaluated using a multifaceted approach that included clinical and administrative data and an assessment of key barriers and facilitators.

During implementation, attending physicians (review 1a) and project clinical risk managers (review 1b) were invited to review 1303 inpatient deaths. Physicians completed 482 reviews (36.99%), rating 21 deaths (4.3%) as potentially preventable. Project clinical risk managers completed reviews for all cases and identified 33 deaths (2.5%) as potentially preventable. Nosocomial infections were the most frequent complication identified in both reviews (Review 1a: 35.02%; Review 1b: 32.92%; κ=0.260). Agreement between physician and risk manager assessments ranged from poor to substantial across checklist sections with particularly low agreement for preventability ratings. Twenty interviews with physicians and project staff identified key barriers to implementing the mortality review, including limited physician resources, redundant documentation, lack of automation, and liability concerns, while perceived usefulness and usability of the review were rated high.

Implementation of a hospital-wide mortality review checklist and associated processes was feasible but constraint by organizational barriers. Although physicians and clinical risk managers identified potentially preventable deaths, inter-rater agreement was low. Sustainable integration into routine care will require substantial adaptations to clinical workflows and organizational structures. As part of a broader patient safety efforts, structured mortality review processes may support learning from inpatient deaths.