Development and Implementation of an Inpatient Mortality Review: a Feasibility Study

Implementation of a hospital-wide mortality review checklist and associated processes was feasible but constraint by organizational barriers. Although physicians and clinical risk managers identified potentially preventable deaths, inter-rater agreement was low. Sustainable integration into routine care will require substantial adaptations to clinical workflows and organizational structures. As part of a broader patient safety efforts, structured mortality review processes may support learning from inpatient deaths.