Tool:
Case review, staff engagement
Problem:
Decrease mortality
Tool Selection:
Mortality rates in hospitals continue to be higher than anticipated. Identification of opportunities for improvement is ongoing. It is important to get frontline input when investigating the root causes of preventable mortality. Participation is important during review of the case.
Usage:
Epic sends an automated email to key staff who cared for the expired patient, asking pertinent questions related to the mortality and asking for input. That information, if requested, is then reviewed by a small group of key leaders who determine if full review by a multidisciplinary team is indicated.
Results:
90-100% of cases had input from at least one of the front-line staff. Mortality O/E ratio improved from 1.64 to 0.80.
