Multidisciplinary Rapid Mortality Review

In our hospital we have a novel quality improvement process called “Rapid Mortality Review (RMR),” which identifies potential patterns, root causes, and systems issues that contribute to mortality. The RMR is a standardized review process of inpatient mortality within 48 hours of death on general medicine and cardiac care unit services. This 15-minute discussion is led by the DOM quality department and involves the treatment team, quality team and clinical documentation specialist. This process assists the group to reflect on every inpatient death, and thus giving the team an opportunity to improve and advance patient care at our facility. Furthermore, it has a humanistic value for all who are involved in the discussion and dignifies the life of a person that was lost.  

The RMR multidisciplinary team includes treating physicians and nurses, chief resident, and quality and clinical documentation specialists. The team is challenged to consider how care could have been better even if death was not preventable, such as getting palliative care consult earlier in the hospital course. A structured review explores goals of care, communication, documentation, systems and quality of care issues. The discussion is on what could have been done differently to improve care even if the death was not preventable. We consider the following factors for improvement: medical errors, misdiagnosis or inappropriate care, delaying in recognition of critical deterioration or treatment, systems issues, and hospice and palliative care issues. In RMR we have the opportunity to learn from every patient! This innovation truly impacts patients and the future care that we deliver to “heal humankind one patient at a time”.  

As a result of this process, over 180 RMR meetings have been conducted over two years. The primary teams characterized 7.2% of deaths as potentially preventable, for reasons such as missed diagnosis, delay in recognition of deterioration, medication toxicity, procedural complication, and an inpatient fall with sequelae. Each of these cases was unique with no clear patterns of harm identified. However, in discussing all deaths, the care teams identified opportunities for improvement in 50%. Issues in advance care planning/end-of-life care were noted in 13% of cases, delays in recognition of deterioration in 9%, communication/teamwork problems in 7%, systems issues in 6%, and medical errors in 3%. Documentation queries resulted in more accurate capture of patient severity of illness and risk of mortality. 44 cases (26%) inspired 64 quality action items. To date, 53% are complete and 34% in progress. Examples of quality interventions implemented include automated drug level monitoring of high risk medications, standardized documentation of advanced care planning, and improved handoff procedures.