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death review, improvement process, mortality review, patient deaths, systems improvement



  1. Rachel, Marcia M. PhD, RN
  2. Stewart, Mary W. PhD, RN


Patients die in hospitals every day; some of these deaths are expected and some are not. Each death can provide information that improves the healthcare system, care provided by healthcare professionals, and hospitalization experience for patients and their families. A standardized mortality review approach in a system focused on quality can set the stage for, and facilitate, the improvement process. This article describes the experience of an academic health center in establishing a mortality review process.