Project Lead : Juliet Higginson
Programme Director : Naomi Fulop
Aims
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To evaluate whether a systematic review of all deaths, and an in-depth assessment of unexpected deaths, can improve patient safety.
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To examine the effectiveness of a new mortality review form to accomplish this.
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To explore the impact of the review outcome data on the wider hospital governance.
Why is this important
Patient safety has now become a national concern and scrutiny of mortality rates has intensified recently in the public media with the extensive coverage of the Healthcare Commission’s investigation and report into Mid Staffordshire Hospital Trust and the release of the Sixth National Adult Cardiac Database Report. Hospital boards need to be assured that all deaths are reviewed and changes made to insure patient safety. Morbidity and Mortality (M&M) meetings have the potential to be instrumental in achieving this.
The effectiveness of these meetings to achieve improved patient care and reduce unexpected deaths remains uncertain but studies have shown that for them to accomplish this effectively they need to have a structured way of identifying what happened, why it happened and implement interventions to reduce the possibility of a similar event re-occurring.
Who is involved?
In May 2009 we looked at the way care groups across the hospital reviewed and learnt from the circumstances of deaths and found considerable variation in the structures and processes used to accomplish this through their morbidity and mortality meetings. As a result of these findings and in collaboration with the Trust’s Mortality Working Group, we have developed a mortality review form to help standardise the process and support systematic identification of issues and corrective measures, to reduce the likelihood of systems and process failures being repeated.
During December 09 to March 2010, we will test the mortality review form in two divisions of the hospital and will evaluate the impact that the form has on M&M meeting structures and format. We will interview clinicians involved in those M&M meetings to explore their views on implementing the form. We will also examine how data arising from the review form can inform the wider trust governance structures.
Possible outcomes
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A standard process for systematically reviewing deaths.
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A process that could reduce the risk of reoccurrence of any system or process failure.
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Identification of common areas for improvement by the Trust.
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Potential reporting structure into the trust governance framework and intelligence for Board assurance.
