Lau H, Litman KC. Saving lives by studying deaths: Using standardized mortality reviews to improve inpatient safety. Joint Commission Journal on Quality and Patient Safety. 2011 Sep;37(9):400-408.
Substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals in the Kaiser Permanente system. In 2008, multidisciplinary teams at KP used the IHI Global Trigger Tool, along with other tools, to investigate hospital-level mortality in order to identify patterns of potential harm and focus improvement efforts.
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