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Rate of Preventable Mortality in Hospitalized Patients: a Systematic Review and Meta-analysis



The number of preventable inpatient deaths in the USA is commonly estimated as between 44,000 and 98,000 deaths annually. Because many inpatient deaths are believed to be preventable, mortality rates are used for quality measures and reimbursement. We aimed to estimate the proportion of inpatient deaths that are preventable.


A systematic literature search of Medline, Embase, Web of Science, and the Cochrane Library through April 8, 2019, was conducted. We included case series of adult patients who died in the hospital and were reviewed by physicians to determine if the death was preventable. Two reviewers independently performed data extraction and study quality assessment. The proportion of preventable deaths from individual studies was pooled using a random-effects model.


Sixteen studies met inclusion criteria. Eight studies of consecutive or randomly selected cohorts including 12,503 deaths were pooled. The pooled rate of preventable mortality was 3.1% (95% CI 2.2–4.1%). Two studies also reported rates of preventable mortality limited to patients expected to live longer than 3 months, ranging from 0.5 to 1.0%. In the USA, these estimates correspond to approximately 22,165 preventable deaths annually and 7150 deaths for patients with greater than 3-month life expectancy.


The number of deaths due to medical error is lower than previously reported and the majority occur in patients with less than 3-month life expectancy. The vast majority of hospital deaths are due to underlying disease. Our results have implications for the use of hospital mortality rates for quality reporting and reimbursement.

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PROSPERO registration number CRD42018095140.

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  1. 1.

    Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America IoM. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.

  2. 2.

    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370–376.

  3. 3.

    Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261–271.

  4. 4.

    Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

  5. 5.

    Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it matters. BMJ Qual Saf. 2017;26(5):423–428.

  6. 6.

    Sox HC Jr, Woloshin S. How many deaths are due to medical error? Getting the number right. Eff Clin Pract. 2000;3(6):277–283.

  7. 7.

    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–2012.

  8. 8.

    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

  9. 9.

    Grey Matters: a practical tool for searching health-related grey literature. 2018; https://www.cadth.ca/resources/finding-evidence/grey-matters. Accessed 24 July 2018.

  10. 10.

    Jackson JL, Kuriyama A, Anton A, et al. The Accuracy of Google Translate for Abstracting Data From Non-English-Language Trials for Systematic Reviews. Ann Intern Med. 2019.

  11. 11.

    Wells GA SB, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 29 Nov 2018.

  12. 12.

    Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014;72(1):39.

  13. 13.

    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188.

  14. 14.

    Freeman MF, Tukey JW. Transformations related to the angular and the square root. Ann Math Stat. 1950:607–611.

  15. 15.

    Engel C, Rasmussen LL, Nielsen JB, Nielsen SF. [Potentially preventable deaths in a medium sized community hospital]. Ugeskr Laeger. 2007;169(33):2630–2633.

  16. 16.

    Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737–745.

  17. 17.

    Sorinola OO, Weerasinghe C, Brown R. Preventable hospital mortality: learning from retrospective case record review. JRSM Short Rep. 2012;3(11):77.

  18. 18.

    Baines RJ, Langelaan M, de Bruijne MC, Wagner C. Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study. BMJ Open. 2015;5(7):e007380.

  19. 19.

    Hogan H, Zipfel R, Neuburger J, Hutchings A, Darzi A, Black N. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. BMJ. 2015;351:h3239.

  20. 20.

    Flaatten H, Brattebo G, Alme B, et al. Adverse events and in-hospital mortality: an analysis of all deaths in a Norwegian health trust during 2011. BMC Health Serv Res. 2017;17(1):465.

  21. 21.

    Kobewka DM, van Walraven C, Taljaard M, Ronksley P, Forster AJ. The prevalence of potentially preventable deaths in an acute care hospital: A retrospective cohort. Medicine (Baltimore). 2017;96(8):e6162.

  22. 22.

    Rogne T, Nordseth T, Marhaug G, et al. Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review. BMJ Qual Saf. 2019;28(1):49–55.

  23. 23.

    Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109(7):582–589.

  24. 24.

    Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4):415–420.

  25. 25.

    Ksouri H, Balanant PY, Tadie JM, et al. Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice. Am J Crit Care. 2010;19(2):135–145; quiz 146.

  26. 26.

    Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? Crit Care. 2015;19:154.

  27. 27.

    Roberts AP, Morrow G, Walkley M, et al. From research to practice: results of 7300 mortality retrospective case record reviews in four acute hospitals in the North-East of England. BMJ Open Qual. 2017;6(2):e000123.

  28. 28.

    Best WR, Cowper DC. The ratio of observed-to-expected mortality as a quality of care indicator in non-surgical VA patients. Med Care. 1994;32(4):390–400.

  29. 29.

    Lu TC, Tsai CL, Lee CC, et al. Preventable deaths in patients admitted from emergency department. Emerg Med J. 2006;23(6):452–455.

  30. 30.

    Klein DO, Rennenberg R, Koopmans RP, Prins MH. The ability of triggers to retrospectively predict potentially preventable adverse events in a sample of deceased patients. Prev Med Rep. 2017;8:250–255.

  31. 31.

    Hall M, Levant S, DeFrances C. Trends in Inpatient Hospital Deaths: National Hospital Discharge Survey, 2000–2010. 2013; https://www.cdc.gov/nchs/products/databriefs/db118.htm. Accessed 28 Sept 2018.

  32. 32.

    Manaseki-Holland S, Lilford RJ, Te AP, et al. Ranking Hospitals Based on Preventable Hospital Death Rates: A Systematic Review With Implications for Both Direct Measurement and Indirect Measurement Through Standardized Mortality Rates. Milbank Q. 2019;97(1):228–284.

  33. 33.

    Pross C, Geissler A, Busse R. Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability. Milbank Q. 2017;95(1):136–183.

  34. 34.

    Ioannidis JP. Are mortality differences detected by administrative data reliable and actionable? JAMA. 2013;309(13):1410–1411.

  35. 35.

    Lilford R, Mohammed MA, Spiegelhalter D, Thomson R. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. Lancet. 2004;363(9415):1147–1154.

  36. 36.

    Lilford R, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won't go away. BMJ. 2010;340:c2016.

  37. 37.

    Holloway RG, Quill TE. Mortality as a measure of quality: implications for palliative and end-of-life care. JAMA. 2007;298(7):802–804.

  38. 38.

    Costa V, Earle CC, Esplen MJ, et al. The determinants of home and nursing home death: a systematic review and meta-analysis. BMC Palliat Care. 2016;15:8.

  39. 39.

    Zegers M, de Bruijne MC, Wagner C, Groenewegen PP, van der Wal G, de Vet HC. The inter-rater agreement of retrospective assessments of adverse events does not improve with two reviewers per patient record. J Clin Epidemiol. 2010;63(1):94–102.

  40. 40.

    Kochanek K, Murphy S, Xu J, Arias E. Deaths: Final Data for 2017. Natl Vital Stat Rep. 2019. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_09-508.pdf. Accessed 7 Oct 2019.

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Correspondence to Benjamin A. Rodwin MD.

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Prior presentations Society of Hospital Medicine National Conference, March 2019. Society of General Internal Medicine National Conference, May 2019

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Rodwin, B.A., Bilan, V.P., Merchant, N.B. et al. Rate of Preventable Mortality in Hospitalized Patients: a Systematic Review and Meta-analysis. J GEN INTERN MED (2020). https://doi.org/10.1007/s11606-019-05592-5

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  • patient safety
  • preventable death
  • medical error