Learning from Deaths with Comprehensive Mortality Review

August 17, 2020 RLDatix Marketing

According to the Health Service Executive (HSE), the are a total of 32 instances in which death must be reported to the coroner in Ireland including maternal deaths, neonatal deaths and mental health deaths. The HSE’s 2019-2024 patient safety strategy Commitment 5: Using Information to Improve Patient Safety highlights their commitment to “... use information from various sources to provide intelligence that will help us recognise when things go wrong, learn from and support good practice and measure, monitor and recognise improvements in patient safety.” This commitment emphasises the importance of not only recording incidents and mortalities, but of providers using the recorded data around these instances to drive patient safety improvements across their organisations.

In collaboration with HSE, The National Office for Clinical Audit (NOCA) conducts the National Audit of Hospital Mortality (NAHM), with the main objective of analysing Hospital In-Patient Enquiry (HIPE) data for the purpose of identifying and trending mortality in acute hospitals across the nation. The audit aims to understand and improve the quality of hospital-based mortality data, stimulate reflection on the quality of overall patient care and identify areas for improvement.

Currently, healthcare organisations in Ireland are primarily focused on reporting mortalities but could see even greater benefits from a system that allows them to conduct their own thorough mortality reviews. For healthcare organisations to be best prepared for the NOCA’s annual survey, they should be equipped with tools that can easily capture mortalities, perform reviews and finally submit data to regulators. By implementing tools such as these, healthcare organisations will be supported in their efforts to learn from mortalities. When healthcare organisations across the nation are equipped with the proper tools to capture and evaluate mortality data, they can better identify gaps where organisation-wide improvements can be made.

Beyond Reporting: How RLDatix Can Help

RLDatix has developed a Mortality Review module specifically designed to help learning from deaths by capturing, reviewing and reporting all mortalities in one system:

The module provides a structured framework: Organisations can report and capture mortality data and document decisions at the level of review/investigation required. The system is fully configurable to support different review methodologies, for example for patients with learning disability, mental health needs, infant or child deaths and stillbirth or maternal deaths.
The module is part of the DatixCloudIQ platform: Providing structured tools to assist with investigation processes. An Investigations module supports the engagement of families throughout the entire process - a key requirement of the 2019 Patient Safety Bill, which requires healthcare organisations be open and honest with patients and families.
Recording of actions: A link to the Investigations module also makes it easy to record the actions taken in response to mortality reviews in order to demonstrate the lessons that have been learned.
Mortality Review offers improved learning: The module has been designed to improve learning from deaths by capturing data, simplifying workflows and highlighting learning points. The module incorporates a two-stage adaptable process, providing the structure required to carry out a formal review or evidence when a review is not required.
Quick production of reports and dashboards: Making it easy to view graphic and statistical information and export data to other systems, as required, for further analysis alongside broader data sources within the organisation. This makes it easy for clinicians to review mortality records, ask screening questions, and analyse and learn from any deficiencies in the care of patients.
The data collated is stored centrally and any updates occur in real time: Utilising the reporting functions and dashboards can allow organisations to provide key data to all relevant staff members. Information on all deaths can be easily displayed on dashboards and queries can be saved. This allows organisations to more efficiently gather important information and easily export it and report to relevant authorities.

RLDatix has created a system that is configurable to the exact needs of individual organisations. It allows mortality reviews to be conducted locally, detail actions to move forward and identify lessons learned, ensuring you remain compliant.

The module is powerful on its own, but it also operates within the wider data collection capabilities of the DatixCloudIQ (DCIQ) platform. Users can delve into a greater level of detail with a link to the Investigations module, which provides tools into root cause analysis for adverse events and highlights recommendations for areas of improvement. Evidence of learning and improvement are available all within the one system.

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