Improving morbidity and mortality in Intensive Care through learning from deaths, and the role of the Structured Judgement Review (SJR) methodology in this process.

Abstract

Learning from deaths occurring in intensive care has been given much focus in the recent years in clinical governance processes in order to improve morbidity and mortality in critically ill patients. When mistakes happen, providers need to understand individual as well as system failures and take necessary steps to avoid recurrences of shortcomings. This involves a well-defined response to deaths including a robust system to review deaths as well as parallel governance processes to reinforce lessons learnt. The Structured Judgement Review (SJR) methodology is being introduced in the UK as a tool for standardising and quantifying analysis of the problems in the care of patients that have died in the ITU. It can be restricted to patients who were expected to survive, and so focus resources into searching for systematic failings of the unit where they are most likely to have occurred. The SJR uses local reviewers to review case notes against a series of specific enquiries and then requires them to score the quality of care against a scale for each criterion. This review is then used to link back to education and focusing of resources within the hospital's ITU and parent teams.

The practice of incident reporting and management: current challenges and opportunities for mental health trusts in England

“…Other methods include “Structured Judgement Review” (SJR) and “systems-based analysis”. SJR is a clinical judgement-based review for analysing the problems in the care of people involved in serious incidents (Siriwardena, 2019; The Royal College of Physicians, 2018). Systems-based analysis is a refined version of RCA that is complemented by other analytical techniques (NHSE and NHSI, 2020a).…”