You've heard the macabre joke that hospitals and doctors "bury their mistakes." Well, here's an interesting twist: At Kaiser Permanente hospitals in Southern California, doctors are doing precisely the opposite. They're rolling back time in the death process – exhuming their unknown mistakes so to speak – to see what, if anything, they can learn in order to save similar patients the next time around.
But they're not doing it the old way through invasive autopsies. Those are expensive, increasingly unpopular with families, forbidden by some religions, and often don't reveal that much about errors in the process of hospital care.
Kaiser's hybrid manual and electronic mortality review uses storytelling and specialists' scrutiny to study medical charts of patients who died in the hospital. The process builds a precise timeline of what happened. The goal is to prevent death and/or improve end-of-life care by looking for places to improve—from ambulatory settings prior to admission to the inpatient bedside.
"Mistakes happen in every hospital. But in the past, there hasn't been a good way to look at trends for people who are dying, trends for people who are (experiencing) harm," says Kerry Litman, MD, Kaiser's director of physician quality and a leader in this effort. Kaiser, with a large sample of deaths among their 3.2 million Southern California enrollees, presents a unique opportunity to aggregate trends, he says.
During a session, "Saving More Lives by Studying Death," at a December Institute for Healthcare Improvement forum in Orlando, Litman joined Helen Lau, RN regional director of hospital performance quality and risk management, and Michael Kanter, MD, medical director of quality and clinical analysis to tell their story.
They began by showing a slide illustrating the course of one sample patient:
80+ patient with dizziness was found to have severe carotid stenosis on Doppler. The results were not reported to the physician, who ‘found’ it during a health maintenance visit eight months later and ordered a vascular surgery consult.
Two weeks later, while being evaluated for a carotid endarterectomy, the patient suffered a major stroke with dysphagia (difficulty swallowing) and was admitted to the hospital. A swallow evaluation was ordered, but oral feeding also started. Swallow evaluation was completed two days later and found high risk for aspiration. However during this time, patient had already developed aspiration pneumonia, from which they [sic] died.
Traditional quality programs might not have identified these problems to allow improvements. Would yours?