Healthcare Mortality Review

HEALTHCARE MORTALITY REVIEW

This Mortality Review documents clinical information, events, and the internal reviewer's assessment of factors contributing to the patient's death. This form is maintained as an internal quality assurance record. The reviewer must complete all applicable sections, certify the accuracy of the information, and record recommendations for system improvement. Unauthorized disclosure of this review is prohibited and may be subject to institutional confidentiality and peer-review protections.

Patient Identification

Patient Name:

Medical Record Number:    Date of Birth:    Gender:

Admission and Death Details

Admission Date:    Discharge Date (if applicable):

Date and Time of Death:    Place of Death:

Clinical Information

Interventions and Procedures

Resuscitation Attempted: Yes No    If yes, duration and outcome:

Palliative Care Consulted: Yes No    Code Status at Time of Death:

Cause of Death and Autopsy

Autopsy Performed: Yes No

Contributing Factors and System Assessment

Select all applicable contributing factors:

Clinical error (diagnostic, therapeutic)
System or process failure (staffing, transfers, equipment)
Delay in recognition or treatment
Communication breakdown (handoff, orders)
Patient-related factors (compliance, advance directives)
Other:

Preventability Assessment

Based on the review of clinical facts and systems, the reviewer assesses the death as:

Clearly preventable — death resulted from error or omission that could reasonably have been prevented
Possibly preventable — care issues may have contributed and improvement could reduce likelihood
Not preventable — death due to progressive disease or expected natural history
Uncertain — insufficient information to determine preventability

Quality of Care Findings and Recommendations

Reviewer Information and Certification

Certification: I certify that I have reviewed the medical record and related materials to the best of my ability, and that the statements and conclusions contained in this review are accurate and complete to the best of my knowledge. This review is for internal quality improvement and peer review purposes.

Attachments and Notes

Relevant laboratory reports
Radiology images/reports
Operative/procedure notes
Progress notes/consults
Autopsy report (if available)

Confidentiality Notice: This document contains protected health information and internal quality review material. It is intended for authorized use only. Distribution beyond authorized personnel must be in accordance with institutional policy and applicable confidentiality protections.

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