Background: Mortality review committees are charged with identifying areas of potential improvement, with the goal of decreasing preventable death. This laudable aim is accompanied by secondary goals of interest to the organization like improving diagnostic error, fostering teamwork, optimizing information technology, or supporting other quality improvement efforts. At our institution, we developed an interdisciplinary mortality review committee charged with improving overall mortality in the hospital, and addressing diagnostic error as a contributing factor.
Purpose: The Institute of Medicine Report from 2015 highlights diagnostic error as an important area for investigation and improvement. “The committee concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Urgent change is warranted to address this challenge.” In response to this call-to-arms, our already-established mortality review committee added additional processes to address diagnostic error in the hospital.
Description: The Mortality Review Committee at The Miriam Hospital is comprised of physician members from 4 clinical departments, representing 7 divisions. Also included on the committee are nursing leadership, chief medical officer, quality nurse, and clinical documentation specialist. Over 14 months the mortality review committee reviewed 24 cases in depth. Cases were pre-screened by a quality nurse and physician leader, and selected for their complex nature. The committee has previously concentrated on improving physician documentation, as well as accuracy of coding. These ongoing processes are now accompanied by an investigation of the clinical care and decision making. Of the examined cases, 21% were judged to have a contribution of diagnostic error. Although this is in keeping with the wide range of published incidence of diagnostic error, it leaves significant room for investigation and improvement. In addition, our committee ascertained that 38% of cases had a missed opportunities to involve palliative care, 50% of cases represented a lapse of communication, 45% of cases included hospital associated events, and 21% of cases represented a failure to rescue. These findings have helped us identify areas of ongoing work or improvement. Additionally, the committee reviews all autopsies, as a way of cross-checking the diagnostic accuracy. To date, 99% of autopsies were consistent with the clinical thinking as described in the chart.
Conclusions: Diagnostic error represents an important yet challenging area for improvement. We describe using the hospital’s mortality review committee as a way to investigate, highlight, and improve the diagnostic process in our hospital.