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e-Autopsy: Kaiser Hospitals Dig In to Data to Assess Mortality

Cheryl Clark, for HealthLeaders Media, February 24, 2011

"Perhaps we find out things that would not have resulted in a different outcome, but they might identify areas where we can improve," Jacobsen said. "Was the patient deteriorating earlier in the case? Could we have responded earlier? Hindsight is always 20-20, but in the midst of the patient coming in, sometimes there are subtle signs and symptoms...that in retrospect, could have been acted on a little earlier."

In the Clostridium difficile project, Litman, Lau, and Kanter are looking at colitis diarrhea, and whether inappropriate antibiotics might have been used. "Although the study did not find a problem with this, it shows e-Autopsy is a new way to look for ways to improve and serve as a 'double check' that good care is being given," Litman said.

So far, there's been so many potential hints of how to improve care, the team plans to expand to other conditions such as gastrointestinal bleeds in patients taking anticoagulant medication, patients with sepsis who recently had an outpatient visit and patients who undergo code blues, including those patients who survive.

I asked Litman if, when he explains e-autopsy to other health providers, does he often hear the joke about hospitals and doctors burying their mistakes?

He smiled. "Now we learn from them too."

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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