Preventable hospital mortality: learning from retrospective case record review

Abstract

Objective: To determine the proportion of hospital deaths associated with preventable problems in care and how they can be reduced.

Design: A two phase before and after evaluation of a hospital mortality reduction programme.

Setting: A district general hospital in Warwickshire, England.

Participants: In Phase 1, 400 patients who died in 2009 at South Warwickshire NHS Foundation Trust had their case notes reviewed. In Phase 2, Trust wide measures were introduced across the whole Trust population to bring about quality improvements.

Main outcome measures: To reduce the crude mortality and in effect the risk adjusted mortality index (RAMI) by 45 in the three years following the start of the programme, from 145 in 2009 to 100 or less in 2012.

Results: In total, 34 (8.5%) patients experienced a problem in their care that contributed to death. The principal problems were lack of senior medical input (24%), poor clinical monitoring or management (24%), diagnostic errors (15%) and infections (15%). In total, 41% (14) of these were judged to have been preventable (3.5% of all deaths). Following the quality improvement programme, crude mortality fell from 1.95% (2009) to 1.56% (2012) while RAMI dropped from 145 (2009) to 87 (2012).

Conclusion: A quality improvement strategy based on good local evidence is effective in improving the quality of care sufficiently to reduce mortality.

Figure 1

The five-year trend in the Crude Mortality and Risk Adjusted Mortality Index (RAMI)