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Learning from mortality and harm reviews

Grant Robinson
Grant Robinson
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‘Would you be happy if this happened to you?’ – If the answer is ‘No’, then it’s likely there was harm.

This guideline from the Institute for Healthcare Improvement (IHI) about conducting a ‘mortality review’ gets to the heart of what we try to do when we get together and study the medical records of patients who have died. Was everything done that should have been done? Was anything done that shouldn’t have been done? If we had done things differently, or better, would this patient still be alive?

There is an increasing awareness of how important it is that we can confidently answer these questions and say that care is safe, that patients receive the right treatments, and that people are not dying unnecessarily.

All the regional health boards in NHS Wales, and Wales’ specialist cancer hospital, have been conducting mortality reviews since 2011. A new white paper called Providing Assurance, Driving Improvement, published by 1000 Lives Plus with the support of the Health Foundation,has captured the key learning points from the Welsh experience.

For me, mortality reviews have been a great help to clarify what is happening on the frontline in my health board. We have learned whether best practice is being followed, and whether people receive the right treatments at the right time.

So far mortality reviews have revealed very few issues of low quality care contributing to patient deaths that had not already been picked up through other channels. But we still need to be honest about areas where we could improve.

For example, we have been able to see opportunities to improve the coordination of treating certain kinds of illness, like sepsis. We have also recognised the need to improve the quality of record-keeping as mortality reviews show up areas where information is missing.

Talking to colleagues across Wales suggests that we are all learning similar things and facing similar issues. Incomplete data seems to be a problem across every organisation – the big question is: how can we fix that?

If we use mortality reviews to identify these issues then we can start to tackle them.

Dr Grant Robinson is Medical Director of Aneurin Bevan Health Board, www.twitter.com/gtmrobinson





 
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Comments
I think mortality and harm review is an excellent tool - looking to see if best practice, right treatment and at the right time was provided. Could we go one better by developing a mainstreamed clinical metrics system that routinely records and monitors these across the service for all patients?
A concern with mortality and harm review is, one, it tends to be a bit too retrospective, and two, tends to capture only extreme/severe gaps in the service. Ongoing monitoring using a service metrics system allows service-wide picture and intervention to occur and picks up early warning trends.
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