Use of Systems Factors Approach to 100% Mortality Review in Pediatric Setting

From the 2022 HVPA National Conference

Veronica Natale (Graduate, Johns Hopkins Hospital), Olivia Lounsbury (Undergraduate), Rebecca Trexler RN, Ann Kane MD


In 2019, an institutional goal of a 100% review of all pediatric mortalities was established to identify and provide insight into areas of improvement. A systems factors approach was implemented to better classify and trend gaps and establish quality improvement initiatives.


A retrospective query of patients reviewed from December 2020 to January 2022 was performed. A total of 101 cases were reviewed and a thematic analysis of systems factors was completed. cases were stored in a secure database that tracks cases reviewed along with systems factors and action items identified. The following levels are used to categorize preventability: Level 1: not preventable due to terminal illness or condition, Level 2: not preventable but medical/system error present, and level 3: possibly preventable with medical/system error present.


Of the 101 cases reviewed, 76% were ICU cases, 10% were inpatient-med-surg, 10% were Peds Emergency Department (PED), and 3% were outside deaths. Cardiology 33%, Neonatal 22%, Pulmonary 14%, and Traumatic 9% causes of deaths had the highest volumes. 10 Systems Factors were used in the framework. 46 cases had no systems factors identified. Of the 55 remaining cases, 60% were attributed to Policies/Guidelines/Education, 31% to information management, 29% to Care Coordination, and 13% to Human Resources. 47% of cases had multiple systems factors identified during the review. During the review process, cases are classified according to their Level of Preventability in which we found that 55% of the original 101 cases were identified as Level 1: Not preventable due to illness or condition, and 46% were classified as Level 2: Not preventable, but medical/systems issue present. None were identified as Level 3: preventable, with medical/systems issues present. 


Thorough review of the identified systems factors could highlight potential areas of improvement where targeted action items and interventions can be implemented to improve the quality of care in pediatric hospitals.

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