Conducting Mortality Reviews

Structures mortality case reviews with root cause analysis and system improvement recommendations for quality improvement in hospital medicine.

Why This Skill Exists

Mortality and Morbidity (M&M) conferences are a cornerstone of medical quality improvement, peer review, and professional accountability. In-hospital mortality rates range from 1.5-3% for general medicine services, and a significant proportion of inpatient deaths — estimated at 10-15% — involve potentially preventable contributing factors related to diagnostic delays, treatment errors, communication failures, or system gaps. The Joint Commission requires hospitals to analyze sentinel events and near-misses, and CMS Conditions of Participation mandate an ongoing quality assessment and performance improvement (QAPI) program.

Mortality reviews serve dual purposes: individual case learning and system improvement. When conducted properly under the protection of peer review statutes (state-specific), mortality reviews are legally privileged and cannot be used in malpractice litigation. This protection enables candid analysis of failures. However, the privilege only applies when reviews follow institutional peer review bylaws, are conducted through an authorized committee, and documentation is appropriately managed. Hospitalists who lead or participate in mortality reviews must understand both the clinical methodology and the legal framework.

Checkpoint A: Pre-Draft Intake (Mandatory)

Before conducting a mortality review, confirm: