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The introduction and impact of a “hot” qualitative mortality reporting system for patients dying within 24 h of admission
  1. Chris Turner

Abstract

Introduction In late 2008 the consultant body at Stafford Hospital Emergency Department introduced and implemented a rapid qualitative review of all patients dying within 24 h of admission to Stafford Hospital. The aim was to identify recurrent themes and implement systematic change to address them.

Method Notes are delivered within 24 h of death to the acute and emergency medicine consultants. Reviews are based on the notes of staff delivering care an supplemented by additional interviews where clarification was required. The aim is to conduct those reviews within days of death. The rapid nature of these reviews means it is often possible to speak with staff while their memory of events is clear.

Analysis Codes and concepts were derived from this and recurrent themes identified. These themes were then investigated and, where possible, a systematic change was introduced to reduce the possibility of this happening again. These issues were reported to departmental governance bimonthly. The following month's mortality data was reviewed with a specific check on the issues that had previously been noted to be a problem. Audits around the solutions put in place were conducted.

Results Problems identified included unreported ECGs, unrecognised sepsis, inappropriate level Drs assessing the sickest patients and inappropriate cardiopulmonary resuscitation. Where issues required input from other departments or services partnerships were formed and we worked in tandem to attempt to resolve systems failures. The outcome of this system has been the introduction of a variety of novel solutions to patient care problems (see other abstract presentations) and a reduction in the HSMR of emergency patients at Stafford Hospital from 150 to 60 for emergency admissions.

Clinical bottom line qualitative mortality reporting when performed by senior clinicians has the potential to identify systematic failings and significantly improve quality of care.

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