Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

摘要: Article-at-a-Glance Background Despite extensive ongoing quality improvement (QI) efforts, substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals Kaiser Permanente, an integrated health care delivery system. In 2008, Permanente developed efficient and effective method for investigating hospital-level to identify patterns of potential harm. Methods The multidisciplinary review process incorporates the Institute Healthcare Improvement Global Trigger Tools 2×2 Mortality Matrix, elements United Kingdom's National Health Service (NHS) 3×2 matrix, two groups questions "deep dive" into issues preventable harm use appropriate settings. Between April 2008 November 2009, teams conducted reviews 50 most recent inpatient deaths at 11 Permanente's Southern California region. An electronic chart abstraction tool facilitated rapid analysis data. De-identified patient narratives portrayed trends from a patient-centered perspective. Results Ten categories were identified, including failure rescue, plan, communicate; that occurred before hospitalization; medication-related events; surgical or procedural-related harm; hospital-acquired infection pressure ulcers; falls; "other." Senior leaders study identified 36 goals response. Conclusions process, which included quantitative data structured qualitative description events, efficiently gathered important information on was not otherwise available, enabling focus efforts.