11/20/19
For this post, we asked one of our Department of Quality and Safety medical directors, Mallika Mendu, MD, MBA, to discuss a mortality-review tool being utilized to drive improvements in medical errors that lead to unnecessary deaths.
Patients depend on hospitals to get the care they need. But sometimes, health care institutions fall short for many different reasons. Research estimates that each year, medical errors cause between 210,000-400,000 deaths nationwide.1 Every one of those deaths represent an opportunity to ask questions, learn from mistakes and improve systems going forward. At Brigham Health, we want to ensure that we learn from every error that contributes to death at our hospital.
Safety science experts have emphasized that the most crucial step towards reducing deaths due to medical errors is rapid identification of these errors and potential errors, or what we refer to as “near-misses.” This identification can be extremely challenging, particularly when a patient’s treatment is complex, involving multiple physicians, medications and procedures.
When we began the process of identifying errors or potential errors at Brigham, we realized the caregivers involved in the patient’s care at the time of death were often the most capable of identifying any potential issues that may have contributed to the patient’s death.
For these reasons, over seven years ago, Brigham Health developed and implemented a hospital-wide electronic tool used to capture real-time information about patient deaths from frontline providers. Using this tool, the team members involved in a patient’s care at the time of death almost immediately receive an email with questions around the circumstances of the patient’s death. The goal is to get providers’ perspective in real time, to understand if there was a medical error that contributed to the death, or if we, in any way, could have done things better. The information provided is then investigated confidentially by safety leadership, and steps are taken to address errors or implement improvements suggested. Using these investigations, our goal is to educate ourselves, and to learn from mistakes moving forward.
Since the implementation of this tool, there have been many positive changes made because of the information provided through these reviews. Some examples include improving our process of transferring patients from other hospitals, improving communication between various teams at the Brigham and enhancing end-of-life conversations led by physician trainees.
Brigham Health believes that we can continue to learn from every death that occurs in the hospital by using this tool and continuing to increase our efforts to promote transparency and feedback from staff. Reflecting on how we can provide better care on an ongoing basis is a key part of our mission.
You can read more about our inpatient mortality review system work in BMJ Quality and Safety, published here.
References:
1Makary MA, Daniel M. Medical Error-The Third Leading Cause of Death in the US. BMJ. 2016 May 3;353:i2139.