Mortality Review Meeting

What is mortality review?

Mortality review is a detailed assessment of all the patients who have died. It is a

resource of improving the governance of patient safety. Mortality reviews are

established to review of deaths of patients as part of professional learning. Information

is systematically collected and then presented in a manner that can be understood.

 Why are mortality reviews important?

• Because they measure the size of the problem i.e. number of deaths and their

causes

• Using data analyses, informed decisions and steps can be taken to avoid future

deaths

• Data can also help in reviewing patient care

 Important Steps of Mortality Review
1. Documenting the number of deaths

2. Collecting basic information related to people who expired

3. Calculating important mortality rates

4. Determining the causes of mortality

5. Looking for avoidable factors and missed opportunities

6. Planning ways to avoid these deaths in future

 Key Factors For Successful Mortality Review

1. Aim to be blame-free but a professionally accountable forum

2. Encourage openness, honesty and transparency of participants

3. Focus on learning and improvement of systems and processes of care

 Adult Mortality Summary
Month : September
Ward :Medical A
Hospital : LRH Peshawar

no Name Age Stay Diagnosis

1 Kursheed 70 yrs 1day CVA with Aspiration Pneumonia
2 Imtiaz 65 yrs 3 day Hemorrhagic Stroke
3 Ameer Hussain 56 yrs 1 day Ischemic CVA
4 Saeed Ullah 75 yrs 1 day Hemorrhagic Stroke
With Aspiration Pneumonia
5 Javaid 45 yrs 2 days Ischemic CVA
 Adult Mortality Summary

no Name Age Stay Diagnosis

6 Dawar khan 45 yrs 3 days CVA with Aspiration Pneumonia
7 Bakht Bilnad 40 yrs 7 days 7BM
8 Ajab Khan 75 yrs 2 day COPD, BPH, Bed Sores
9 Habib ur Rehman 65 yrs 1 day DCLD(IV)
10 Najeeb ullah 70 yrs 1 days Cerebral Malaria, Encephalitis

11 Sher Zayda 25 yrs 1 day DLA

12 Muslim Khan 55 yrs 11 days DM + HTN with C&D
13 Qawi Khan 26 yrs 4 days Pyogenic
14 Abbas 26 yrs 1 day Anaphylactic Shock
15 M. Ibrahim 56 yrs 4 days Septicemia
 Adult Mortality Summary
Month : September
Ward :Medical A
Hospital : LRH Peshawar

no Name Age Stay Diagnosis

1 Hussan Pari 41 yrs 7 days Ischemic CVA, Hypoglycemia brain
incult
2 Maria Bibi 82 yrs 3 days SAH
3 Rehmat Bibi 85 yrs 6 day DCLD Hep Enceph (IV)
4 Raibala Bibi 55 yrs 4 day Non – B, Non- C Cirrhosis
5 Bachai Noor 55 yrs 1 days Hemorrhagic Stroke

6 Sheila Bibi 30 yrs 2 days Hemorrhagic Stroke

7 Sharshad Begum 50 yrs 1 days Hemorrhagic Stroke

 Male Mortality Summary

1 1 1 1 1 1 1 1
S trok e DCLD C ereb ral D &A A n ap h ylactic L ymp h oma P yogen ic TBM D M + HT N
Malaria S h ock Men in gitis C omp lication
 Female Mortality Summary

12

2 3
1
Stroke DCLD Septicemia Undiagnosed
 Case Review
Patient name : Noorshada Bibi
Age : 70 years
Address : Shab Qadar
DOA : 22-9-2018
MOA : Emergency
DM+ and HTN+ = 4years
HCV : Diagnosed
Diagnosis : Necrotizing Fasciitis
P/C:
Left foot severe pain – 5 days
Fever – 4 days
Confusion – 3 days
Left foot swelling – 2 days

Hops: No documentation
Systematic Inquiry : No record
Past Hx, Menstural Hx, Drug Hx, Family and social Hx : not documented
GPE + Systemic Hx : no record
 Management Lacking

• Admitted in Medical –A for 5 days

• Advised 2 hourly RBS monitoring

• 2 episodes of hypoglycemia documented

• Septicemic Patient : Blood culture, wound culture not done

CBC once
RFTS not reported

• IV Antibiotics : Tanzo 2.25g

• Unattended surgical calls
• 3 day delay in debridement
• Critical notes not available
• ICU