ArticleBMJ quality & safety2017
Quality gaps identified through mortality review.
Article in BMJ quality & safety, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 24 papers.
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
24 citing papers in PubMed.
- Trial
- Poor nutrition status associated with low patient satisfaction six months into treatment for head and neck/esophageal cancer treatment: A prospective multicenter cohort study.Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition · 2025Article
- Family Interviews Improve Health Service Recommendations in Mortality Review Process: A Mixed-Methods Assessment.Health expectations : an international journal of public participation in health care and health policy · 2025Article
- Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers.Academic emergency medicine : official journal of the Society for Academic Emergency Medicine · 2025Article
- Development of a novel rapid response event review process for quality improvement.BMJ open quality · 2024Article
- Development of an emergency department end of life care audit tool: A scoping review.International journal of nursing studies advances · 2023Article
- Mortality in the Emergency Department and the Effectiveness of Conventional Safety Event Reporting.Cureus · 2023Article
- Patients admitted on weekends have higher in-hospital mortality than those admitted on weekdays: Analysis of national inpatient sample.American journal of medicine open · 2023Article
- Moving beyond audit: driving system learning using a novel mortality classification system in a tertiary training hospital in Kenya.BMJ open quality · 2023Article
- Reduction in omission events after implementing a Rapid Response System: a mortality review in a department of gastrointestinal surgery.BMC health services research · 2023Article
- Evaluation of the effect of a Nursing System Framework on Nurse Sensitive Indicators, mortality and readmission in an NHS Trust.Nursing open · 2023Observational
- Review of the utility of routine mortality reviews among deaths on General Internal Medicine wards in a Canadian tertiary care hospital.BMJ open quality · 2022Review
- Qualitative exploration of the Medical Examiner role in identifying problems with the quality of patient care.BMJ open · 2021Article
- Article
- The impact of dementia and language on hospitalizations: a retrospective cohort of long-term care residents.BMC geriatrics · 2020Article
- Article
- Observational
- Care trajectory management: A conceptual framework for formalizing emergent organisation in nursing practice.Journal of nursing management · 2019Review
- Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study.BMC nursing · 2019Article
- Are morbidity and mortality case review practices in Scottish intensive care units aligned to national standards?Journal of the Intensive Care Society · 2018Article
Corrections and comments
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundHospital 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.
objectiveTo describe the implementation and results from an institution-wide mortality-review process.
designA 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.
resultsOver 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.
conclusionsOur institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.
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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.