2.50
Hdl Handle:
http://hdl.handle.net/10755/616317
Category:
Full-text
Type:
Poster
Title:
Mortality: Characteristics of Potential Preventable Cases
Author(s):
Dermenchyan, Anna; Simon, Wendy
Lead Author STTI Affiliation:
Gamma Tau-at-Large
Author Details:
Anna Dermenchyan, RN, CCRN-K, adermenchyan@mednet.ucla.edu; Wendy Simon
Abstract:
Session presented on Saturday, July 23, 2016 and Sunday, July 24, 2016: Purpose: Since the 1999 IOM report To Err is Human highlighted that up to 98,000 preventable deaths occur annually in U.S. hospitals, efforts have intensified to understand and eliminate preventable mortality. At our institution, we developed an in-person, near real-time, multidisciplinary mortality review to capture the insight of frontline providers and improve care. In the analysis presented here, we compare the characteristics of deaths deemed potentially preventable and non-preventable. Methods: Over three years, we held over 300 mortality review meetings. As part of the standardized review, the physician and nursing team assesses whether the death was potentially preventable. Deaths were stratified according to this assessment, and continuous variables were evaluated using two sample t-tests and categorical variables with chi-squared or Fisher?s exact tests as appropriate. Results: Of 331 cases reviewed, 22 were deemed potentially preventable (6.7%) and 309 non-preventable (93.3%). Deaths deemed potentially preventable had shorter lengths of stay (mean 6.7 vs. 20.1 days, p=0.04) and were more likely to occur in an ICU setting (63.6% vs. 51.8%, p=0.02). Age and source of admission did not differ significantly. Cases deemed potentially preventable were more likely to be classified as unexpected deaths (47.6% vs. 7.5%, P<0.001). Cases were more likely to be DNR/DNI or comfort care at the time of death (P<0.001 for both), but use of palliative care services and code status at admission did not differ. Code blues were more common in deaths deemed potentially preventable (63.6% vs. 16.5%, p<0.001), and reviewers were more likely to deem the code preventable (35.7% vs. 6.5%, P=0.01). Statistically significant differences in the primary reasons for mortality were seen in deaths deemed potentially preventable versus not preventable (p<0.001). There were more deaths due to acute medical complications, medication adverse events and surgical/procedural complications in the deaths deemed potentially preventable, and more chronic medical conditions and harm occurring before hospitalization in the non-preventable deaths. Opportunities for improvement in care were identified in more of the cases deemed potentially preventable (100% vs 45.3%, P<0.001). Specifically, medical errors (36.4% vs. 2.3% of cases, P<0.001), delays in recognition or treatment of deterioration (36.4% vs. 9.1%, P<0.001), communication/teamwork issues (50% vs. 12.6%, P<0.001) and procedural complications (13.6% vs. 1.3%, P=0.008) were all noted more frequently in deaths deemed potentially preventable. There were no significant differences in systems issues, healthcare-acquired infections/healthcare-associated conditions, or problems with advance care planning. Cases deemed potentially preventable were more likely to inspire quality improvement action items (81.8% vs. 26%, P<0.001). Conclusions: While providers deem a small fraction of inpatient deaths potentially preventable (6.7%), there are significant differences in these cases compared to deaths deemed non-preventable. Many are related to patient risk of mortality, goals of care, and expectedness of death. However, significant differences were also noted in patient care, including medical errors, delays, teamwork and procedural complications. Additionally, significantly more actionable quality opportunities were identified, suggesting that inpatient mortality rates can be further reduced by improving care.
Keywords:
Quality Improvement; Multidisciplinary Team; Hospital Mortality
Repository Posting Date:
13-Jul-2016
Date of Publication:
13-Jul-2016 ; 13-Jul-2016
Other Identifiers:
INRC16PST240; INRC16PST240
Conference Date:
2016
Conference Name:
27th International Nursing Research Congress
Conference Host:
Sigma Theta Tau International, the Honor Society of Nursing
Conference Location:
Cape Town, South Africa
Description:
Theme: Leading Global Research: Advancing Practice, Advocacy, and Policy

Full metadata record

DC FieldValue Language
dc.language.isoenen
dc.type.categoryFull-texten
dc.typePosteren
dc.titleMortality: Characteristics of Potential Preventable Casesen
dc.contributor.authorDermenchyan, Annaen
dc.contributor.authorSimon, Wendyen
dc.contributor.departmentGamma Tau-at-Largeen
dc.author.detailsAnna Dermenchyan, RN, CCRN-K, adermenchyan@mednet.ucla.edu; Wendy Simonen
dc.identifier.urihttp://hdl.handle.net/10755/616317-
dc.description.abstractSession presented on Saturday, July 23, 2016 and Sunday, July 24, 2016: Purpose: Since the 1999 IOM report To Err is Human highlighted that up to 98,000 preventable deaths occur annually in U.S. hospitals, efforts have intensified to understand and eliminate preventable mortality. At our institution, we developed an in-person, near real-time, multidisciplinary mortality review to capture the insight of frontline providers and improve care. In the analysis presented here, we compare the characteristics of deaths deemed potentially preventable and non-preventable. Methods: Over three years, we held over 300 mortality review meetings. As part of the standardized review, the physician and nursing team assesses whether the death was potentially preventable. Deaths were stratified according to this assessment, and continuous variables were evaluated using two sample t-tests and categorical variables with chi-squared or Fisher?s exact tests as appropriate. Results: Of 331 cases reviewed, 22 were deemed potentially preventable (6.7%) and 309 non-preventable (93.3%). Deaths deemed potentially preventable had shorter lengths of stay (mean 6.7 vs. 20.1 days, p=0.04) and were more likely to occur in an ICU setting (63.6% vs. 51.8%, p=0.02). Age and source of admission did not differ significantly. Cases deemed potentially preventable were more likely to be classified as unexpected deaths (47.6% vs. 7.5%, P<0.001). Cases were more likely to be DNR/DNI or comfort care at the time of death (P<0.001 for both), but use of palliative care services and code status at admission did not differ. Code blues were more common in deaths deemed potentially preventable (63.6% vs. 16.5%, p<0.001), and reviewers were more likely to deem the code preventable (35.7% vs. 6.5%, P=0.01). Statistically significant differences in the primary reasons for mortality were seen in deaths deemed potentially preventable versus not preventable (p<0.001). There were more deaths due to acute medical complications, medication adverse events and surgical/procedural complications in the deaths deemed potentially preventable, and more chronic medical conditions and harm occurring before hospitalization in the non-preventable deaths. Opportunities for improvement in care were identified in more of the cases deemed potentially preventable (100% vs 45.3%, P<0.001). Specifically, medical errors (36.4% vs. 2.3% of cases, P<0.001), delays in recognition or treatment of deterioration (36.4% vs. 9.1%, P<0.001), communication/teamwork issues (50% vs. 12.6%, P<0.001) and procedural complications (13.6% vs. 1.3%, P=0.008) were all noted more frequently in deaths deemed potentially preventable. There were no significant differences in systems issues, healthcare-acquired infections/healthcare-associated conditions, or problems with advance care planning. Cases deemed potentially preventable were more likely to inspire quality improvement action items (81.8% vs. 26%, P<0.001). Conclusions: While providers deem a small fraction of inpatient deaths potentially preventable (6.7%), there are significant differences in these cases compared to deaths deemed non-preventable. Many are related to patient risk of mortality, goals of care, and expectedness of death. However, significant differences were also noted in patient care, including medical errors, delays, teamwork and procedural complications. Additionally, significantly more actionable quality opportunities were identified, suggesting that inpatient mortality rates can be further reduced by improving care.en
dc.subjectQuality Improvementen
dc.subjectMultidisciplinary Teamen
dc.subjectHospital Mortalityen
dc.date.available2016-07-13T11:09:46Z-
dc.date.issued2016-07-13-
dc.date.issued2016-07-13en
dc.date.accessioned2016-07-13T11:09:46Z-
dc.conference.date2016en
dc.conference.name27th International Nursing Research Congressen
dc.conference.hostSigma Theta Tau International, the Honor Society of Nursingen
dc.conference.locationCape Town, South Africaen
dc.descriptionTheme: Leading Global Research: Advancing Practice, Advocacy, and Policyen
All Items in this repository are protected by copyright, with all rights reserved, unless otherwise indicated.