IIPatient safety

ED death review completion

Whether every death in (or shortly after) the ED is reviewed in a structured, blame-free way to learn from it. The number itself is process — but the learning behind it is where preventable deaths get prevented.

Capture & escalation pipeline

From every ED death to a structured review, agreed actions, and closure.

How it’s measured

Numerator: ED deaths that undergo a completed structured mortality review within the defined timeframe.
Denominator: All ED deaths in the period.
Formula: (Numerator ÷ Denominator) × 100, with a sub-measure for deaths judged potentially preventable.
Unit: % of deaths reviewed

Target

India

India: NABH expects a death/mortality review process; aim for 100% of ED deaths reviewed, with structured grading of preventability.

Global

International: Aligns with structured judgement review methods (e.g. RCEM/SJR-style) — review all deaths, grade care quality and avoidability.

The goal is 100% reviewed AND actions closed — a review with no follow-through is just paperwork.

Who does what

The clinical chain of responsibility at the bedside.

Treating team	Documents the clinical course and contributes facts to the review honestly.
ED clinical lead / reviewer	Conducts the structured review, grades care and preventability, and proposes actions.
Mortality review committee	Validates findings, agrees actions, and tracks them to closure.
Medical records / HIM	Identifies all deaths and assembles the records for review.

What to capture & how it’s automated

Who captures it

Medical records (death identification) and the clinical lead / committee (review completion).

What is captured

Every ED death, the review status, the structured-judgement findings, preventability grade, and resulting actions.

Manual reality

Deaths tracked from the death register; reviews recorded in minutes. Without a tracker, some deaths are never reviewed and actions are not followed up.

Automated in real life

The HMIS flags every ED death into a review worklist with due dates, the structured review is captured on a form, and an action tracker keeps items open until closed.

Who in the hospital is involved

Beyond the bedside — the functions that make capture and improvement happen.

Mortality review committee	Owns the process, governance, and action closure.
Quality cell	Tracks completion rate, preventability trends, and reports to leadership/accreditation.
Medical records / HIM	Ensures no death is missed and records are complete.
IT	Builds the death-to-review worklist and action tracker.
Medico-legal / administration	Handles statutory death reporting and any medico-legal aspects separately from the learning review.

Why it affects performance

A complete, structured mortality review is a NABH governance requirement and a hallmark of a learning organisation. The preventability grade and closed actions are what turn deaths into system improvements.

Why it affects patient care

Reviewing every death catches recurring failure modes — missed sepsis, delayed escalation, airway disasters — and fixes them before the next patient. It is how an ED stops repeating fatal mistakes.

Capture pitfalls & gaming to watch for

Treating it as a tick-box: reviews 'completed' but no actions or closure.
A blame-focused review that makes staff defensive and hides facts.
Missing deaths (e.g. brought-in-dead or transferred-then-died) from the denominator.
Confusing the learning review with statutory/medico-legal death reporting.

What actually moves the number

A structured-judgement review template and trained reviewers.
A clear just-culture charter separating learning from blame.
An action tracker with owners and due dates, reviewed at committee.
Automated identification of every death into the review list.
Themed feedback to the whole department, not just the committee.

References

Freely citable

Compiled from contemporary emergency-medicine quality practice and freely citable accreditation and guideline standards. Educational use only.