Turbocharging the Mortality Review System in a healthcare organization

Preventable medical errors have already prompted hospitals and acute care facilities to invest millions of dollars in technology to improve quality of care, but that’s not enough to “avoid the avoidable.”

While mortality and morbidity reviews are now conducted in nearly every hospital, a recent study by Baltimore-based Johns Hopkins unveils that the third leading cause of death in the United States remains preventable medical errors during hospitalization. That means around 400,000 lives are lost each year to avoidable errors in patient care1.

There may not be a single solution to reduce hospital deaths, but there are ways to integrate, fine-tune, and turbo-charge the systems that study them.


Room For Improvement: The Institution-Wide Mortality Review System

Departmental efforts to investigate mortality and morbidity rates are commonplace throughout healthcare organizations. However, institution-wide mortality and morbidity review systems are often patchwork quilts of disparate data lacking the cohesion to track, analyze, and report on causes of death.

So how do healthcare organizations reduce the likelihood of the same mistake being repeated? This comes down to the healthcare organization having an effective system in place to provide actionable insights and visibility into the care issues contributing to adverse events and patient deaths including:

  • Patient and visit information
  • Discharge information and clinical diagnosis with ICD-9 or ICD-10 codes
  • Autopsy summary
  • Case summary
  • Patient story
  • Opportunities for improvement
  • Problem points with a reliability classification

At Fortude, we’ve come a long way from the first mortality and morbidity review systems. Fortude’s Mortality Review System is based on real feedback from clinicians at a leading US healthcare system and is designed to eliminate bias from the review process.

1 Results based on a case study with leading healthcare systems

In a recent study, the Fortude Mortality Review System identified up to 26 percent more avoidable errors, with a seven-fold increase in actionable insights over traditional mortality and morbidity reviews.2 The new system, developed and implemented by Fortude, also reduced the mortality rate up to 11.8 percent and saved up to 0.2% more lives.3

Connecting existing platforms, EMRs, and legacy systems is the key to easier data review. With targeted data collection, healthcare professionals can identify process improvements across the entire care system (or department-by department) that reduces the likelihood of repeating the same mistake. By reducing error – including fine-tuning guidelines and identifying new practice measures – higher patient satisfaction scores are well within reach.

Recent studies show that hospitals with lower inpatient mortality rates also tend to have higher patient satisfaction scores. For example, a 25 percent change in mortality will yield similar changes in patient satisfaction.4

Fortude’s Mortality Review System is an enterprise-level quality and process improvement solution for hospitals and acute care facilities designed to identify system frailties leading to death and is a customizable solution that can be implemented in as few as four weeks. The system drives best-practice behaviors and provides an opportunity to learn from post-mortality review leading to identification of antecedents and preventable patient deaths.


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