Learning from every death

The concepts of peer review and the venerable morbidity and mortality conference are familiar improvement approaches to health care providers. These 2 entities are typically provider or patient centric and are not typically extended within hospitals and health systems as a tool for organizational learning for care process or system failures. Out of a desire to deepen our understanding and accelerate learning about quality and safety opportunities in our hospitals, Mayo Clinic embarked on journey to analyze the stories of all patient deaths. This paper illuminates the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System (Rochester, MN).