Our program has evolved over the past 13 years as an extension of the M & M tradition at Mayo’s flagship hospital in Rochester. The leadership initially challenged us to create a meaningful mechanism to review hospital deaths that could quantify unanticipated deaths and related adverse events and generate system-level improvements.
Things really took off after we uncovered two patient stories dramatizing the need for practice change through a systematic review of 100 deaths, which I initiated following several years of fruitless work with the IHI Global Trigger Tool.
Now each case is reviewed by at least one physician and one nurse prior to committee discussion during which we seek to develop consensus around the improvement opportunities identified. Nurses have an equal voice. We escalate expertise in the review process by asking the associated department chair or service chief to identify a knowledgeable, empathetic, systems-savvy physician to contribute to the review process. In order to distance the program from the peer review mindset, we do not record the names of clinicians who were involved in the patient’s care.
We found that language is important. We abandoned the term adverse event in favor of process failures, issues and opportunities. We examine the entire journey from presentation to death with a view to uncovering any opportunity for improvement. Most often we find errors of omission had the greatest impact.
The program was so successful in generating sustainable practice improvement that we gradually extended the program to include all Mayo system affiliates. While we widely share knowledge of identified improvement opportunities, each facility handles implementation of process change locally. A home-grown database has allowed us to uncover additional improvement opportunities that would have been missed without aggregate analysis of findings. It has also helped us identify best practices suitable for adoption across the system.
We have recently extended the process to examine other patient cohorts including readmissions, high cost, respiratory failure, sepsis and post-op bleeding. We have also launched a learning collaborative and are inviting all organizations to join us in the effort who are willing to commit to a review of 100 deaths during the first 6 months of 2017. Please contact me for more information if you are interested in participating.
For more information about our results, see: Huddleston JM, Diedrich DA, Kinsey GC, Enzler MJ, Manning DM. Learning from every death. J Patient Saf. 2014;10(1):6-12. doi: 10.1097/PTS.0000000000000053.
First and foremost, never forget the transformative power of narrative.
Jeanne M Huddleston, MD, MS
Chair, Morbidity and Mortality Council
Mayo Clinic, Rochester Campus
507.316.1118