SHM Converge Scientific Abstract ePoster Gallery-Comparing Retrospective and Real-Time Mortality Reviews

Pdf Summary

This study compared two mortality review methods at a large academic hospital over 12 months: retrospective committee-based review and real-time physician survey review.

<strong>Retrospective review:</strong>  
- 653 deaths occurred; 326 cases were randomly assigned for review.  
- 136 reviews were completed, a 20.8% completion rate.  
- Reviewers found opportunities for improvement (OFIs) in 96 cases (70.6%).  
- A total of 272 OFIs were identified, averaging 2.8 per case.  
- The most common OFI categories were end-of-life care, treatment/care, and documentation.

<strong>Real-time review:</strong>  
- 759 deaths were reviewed through an automated survey sent to the attending physician.  
- The response rate was 60.3%.  
- OFIs were identified in 114 cases (24.9%).  
- A total of 131 OFIs were found, averaging 1.1 per case.  
- The top OFI categories were end-of-life care, surgical/procedural issues, and treatment/care.

<strong>Key differences:</strong>  
- Real-time review identified more surgical/procedural issues than retrospective review (16% vs. 4.4%).  
- Communication issues were also more common in real-time review (7.6% vs. 3.6%).  
- Documentation problems were much more common in retrospective review (9.2% vs. 0.76%).  
- Both methods found end-of-life care as the largest category of concern, and both had similar rates of treatment/care issues.

<strong>Conclusion:</strong>  
Retrospective reviews produced more detailed findings and more OFIs per case, while real-time reviews captured bedside perspectives that may not appear clearly in the medical record, especially around procedures and communication. Using both methods together gives a more complete view of patient safety problems and improvement opportunities.

Asset Subtitle

Taylor Wootton

Meta Tag

Author List Sonja Bartolome, Taylor Wootton

Category Research

Concept Mortality Review

Concept Improvement Opportunity

Concept End-of-Life Care

Concept Retrospective Review

Concept Real-Time Review

Distinguished Non-Finalist

Presenter Organization UT Southwestern Medical Center

Presenting Author Taylor Wootton

Track Patient Safety

Keywords

mortality review

retrospective review

real-time survey

opportunities for improvement

patient safety

end-of-life care

documentation issues

surgical complications

communication issues

academic hospital

Mortality Review

Improvement Opportunity

End-of-Life Care

Retrospective Review

Real-Time Review