Surveying Care Teams after in-Hospital Deaths to Identify Preventable Harm and Opportunities to Improve Advance Care Planning

Published:November 22, 2017DOI:


      Reviewing in-hospital deaths is one way of learning how to improve the quality and safety of care. Postdeath surveys sent to the care team for patients who died may have a role in identifying opportunities for improvement. As part of a quality improvement initiative, a postdeath care team survey was developed to explore how it might augment the existing process for learning from deaths.


      A survey was sent to the care team for all inpatient deaths on the hospital medicine and medical ICU services at one institution. Survey responses were reviewed to identify cases that required further investigation. An iterative process of inductive coding was used to create a coding taxonomy to classify survey response free-text comments.


      During the distribution period (September 25, 2015–December 28, 2015), 82 patients died, and 191 care team members were surveyed. Responses (138; 72.3% response rate) were collected through January 28, 2016. Based on the survey responses, 5 patients (6.1%) not identified by other review processes were investigated further, resulting in the identification of several important opportunities for improvement. The free-text comment analysis revealed themes around the importance of advance care planning in seriously ill patients, as well as evidence of the emotional and psychological strain on clinicians who care for patients who die.


      Postdeath care team surveys can augment mortality review processes to improve the way hospitals learn from deaths. Free-text comments on such surveys provide information not otherwise identified during traditional mortality review processes, including the importance of advance care planning and the strain on clinicians whose patients die.
      To read this article in full you will need to make a payment


      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hall M.J.
        • Levant S.
        • DeFrances C.J.
        Trends in inpatient hospital deaths: National Hospital Discharge Survey, 2000–2010.
        NCHS Data Brief. 2013; 118 (Accessed Oct 1, 2017): 1-8
        • Gupta K.
        • Wachter R.M.
        • Kachalia A.
        Financial incentives and mortality: taking pay for performance a step too far.
        BMJ Qual Saf. 2017; 26: 164-168
        • Shojania K.G.
        • Dixon-Woods M.
        Estimating deaths due to medical error: the ongoing controversy and why it matters.
        BMJ Qual Saf. 2017; 26: 423-428
        • Provenzano A.
        • et al.
        Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.
        BMJ Qual Saf. 2015; 24: 31-37
        • Redinbaugh E.M.
        • et al.
        Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors.
        BMJ. 2003; 327 (Jul 26): 185
        • Sansone R.A.
        • Sansone L.A.
        Physician grief with patient death.
        Innov Clin Neurosci. 2012; 9: 22-26
        • Higgins P.C.
        • Garrido M.M.
        • Prigerson H.G.
        Factors predicting bereaved caregiver perception of quality of care in the final week of life: implications for health care providers.
        J Palliat Med. 2015; 18: 849-857
        • Steinhauser K.E.
        • et al.
        What constitutes quality of family experience at the end of life? Perspectives from family members of patients who died in the hospital.
        Palliat Support Care. 2015; 13: 945-952
        • Huddleston J.M.
        • et al.
        Learning from every death.
        J Patient Saf. 2014; 10: 6-12
        • Lau H.
        • Litman K.C.
        Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.
        Jt Comm J Qual Patient Saf. 2011; 37: 400-408
        • Barbieri J.S.
        • et al.
        The Mortality Review Committee: a novel and scalable approach to reducing inpatient mortality.
        Jt Comm J Qual Patient Saf. 2013; 39: 387-395
        • Kobewka D.M.
        • et al.
        Quality gaps identified through mortality review.
        BMJ Qual Saf. 2017; 26: 141-149
        • Heslin M.J.
        • et al.
        A 100% departmental mortality review improves observed-to-expected mortality ratios and University HealthSystem Consortium rankings.
        J Am Coll Surg. 2014; 218: 554-562
        • Weissman J.S.
        • et al.
        Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?.
        Ann Intern Med. 2008; 149 (Jul 15): 100-108
        • Gupta M.
        • et al.
        Preventable mortality: does the perspective matter when determining preventability?.
        J Surg Res. 2013; 184: 54-60
        • Society of Hospital Medicine
        Rapid Mortality Review: Transforming Mortality Review Promotes Change and Reduces Risk-Adjusted Mortality.
        (Simon W, et al. Abstract 295)
        • Dijkema L.M.
        • et al.
        Real-time information on preventable death provided by email from frontline intensivists: results in high response rates with useful information.
        BMJ Qual Saf. 2015; 24: 288
        • NEJM Catalyst
        The Practice of Respect.
        (Sokol-Hessner L, Folcarelli P, Sands K; Jun 23)
        • Sokol-Hessner L.
        • Folcarelli P.H.
        • Sands K.E.
        Emotional harm from disrespect: the neglected preventable harm.
        BMJ Qual Saf. 2015; 24: 550-553
        • Dzeng E.
        • et al.
        Moral distress amongst American physician trainees regarding futile treatments at the end of life: a qualitative study.
        J Gen Intern Med. 2016; 31: 93-99
        • van Pelt F.
        Peer support: healthcare professionals supporting each other after adverse medical events.
        Qual Saf Health Care. 2008; 17: 249-252
        • US Department of Health and Human Services
        Health Information Privacy: HIPAA for Professionals.
        (Updated: Jun 16, 2017)
        • Bernacki R.E.
        • Block S.D.
        • American College of Physicians High Value Care Task Force
        Communication about serious illness care goals: a review and synthesis of best practices.
        JAMA Intern Med. 2014; 174: 1994-2003


      David Lucier, MD, MBA, MPH, CPPS, formerly Fellow of Patient Safety and Quality, Harvard Medical School, Boston, is Director of Quality Improvement and Patient Safety, Hospital Medicine, Massachusetts General Hospital, Boston.


      Patricia Folcarelli, RN, MA, PhD, is Vice President, and Cheryle Totte, RN, MS, is Director of Patient Safety, Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, Boston.


      Alexander R. Carbo, MD, is Director of Quality Improvement, Department of Medicine, Beth Israel Deaconess Medical Center, Boston.


      Lauge Sokol-Hessner, MD, is Site Director, Harvard Medical School Fellowship in Patient Safety and Quality, Boston, and Associate Director of Inpatient Quality, Department of Health Care Quality, Beth Israel Deaconess Medical Center.