Background: Mortality reviews are a cornerstone of patient safety and quality improvement efforts. Increasingly, electronic medical record and web-based tools are leveraged to identify gaps in quality of care through retrospective or real-time mortality reviews. However, studies have yet to compare results when utilizing both review methods in the same patient cohort. This study aims to compare data from retrospective and real-time mortality reviews conducted over the course of a 12-month period in a large academic hospital.

Methods: Retrospective reviews are conducted by a committee comprised of physicians and nurses from a variety of adult specialties. Fifty percent of mortalities, randomly chosen based on medical record number, are assigned for members to review and then present to the committee for consensus. In contrast, a real-time mortality review tool (MRT) was developed to gain the perspective of the physician at the bedside. This tool automatically emails the attending of record at the time of a patient’s death and requests the completion of a 10-question survey, identifying safety issues and offering an opportunity to recognize a colleague or request support. The MRT surveys all adult patient deaths, including patients admitted to inpatient hospice, who are excluded from the retrospective review. Data from both review methods is analyzed using a web-based patient safety software platform.

Results: Of 653 deaths, 326 cases were assigned for retrospective review, and 136 case reviews were completed (20.8%). Opportunities for improvement (OFIs) were noted in 96 cases (70.6%). A total of 272 OFIs were found (average of 2.8 per case). The top 3 OFI categories were end of life opportunities (59/272, 21.7%), treatment/care opportunities (26/272, 9.6%), and documentation opportunities (25/272, 9.2%). In contrast, a total of 759 MRT surveys were sent with a response rate of 60.3%. OFIs were identified in 114/458 cases, with a total of 131 OFIs (average of 1.1 per case). The top 3 OFI categories were end of life opportunities (28/131, 21.4%), surgical/procedural opportunities (21/131, 16%), and treatment/care opportunities (16/131, 12.2%). In comparison, surgical/procedural opportunities comprised 16% (21/131) of all OFIs in the MRT but only 4.4% (12/272) in the retrospective review. Communication opportunities were twice as common in the MRT (10/131, 7.6% versus 10/272, 3.6%), while documentation opportunities were identified more commonly in the retrospective review (25/272, 9.2% versus 1/131, 0.76%). Both groups found the largest number of OFIs with end of life care, particularly with the need for timely palliative consultation and clarification of goals of care. Additionally, both groups found similar rates of treatment/care opportunities, mostly with concerns around delays in care.

Conclusions: Retrospective and real-time mortality reviews offer unique perspectives on patient deaths. Retrospective reviewers provide more detailed reviews which yield a greater number of safety concerns per case, while real-time provider reviews highlight information that might not be as apparent in the written record, including information related to surgical/procedural complications and communication opportunities. Combining both review methods offers a more robust picture of patient safety vulnerabilities and opportunities to improve care.

IMAGE 1: RETROSPECTIVE MORTALITY REVIEW

IMAGE 2: REAL-TIME MORTALITY REVIEW