The research team, led by Trine Sand Kaastad and Trond-Eirik Strand, set out to quantify a figure that has proven notoriously difficult to pin down. Existing literature places the proportion of preventable in-hospital deaths anywhere between 0.5 and 8.4 percent, a range so wide that it offers hospitals and health authorities little practical guidance. That uncertainty stems largely from the method at the heart of the study: retrospective case record review, or RCRR, in which trained reviewers comb through patient charts after death to determine whether harm from care, rather than the underlying disease, contributed to the outcome. The technique is considered the gold standard for assessing preventable deaths, but it has a well-documented weakness, namely that different reviewers looking at the same record can reach strikingly different conclusions.

To confront that problem, the researchers adopted a design that few studies of this kind have attempted. All 1,081 in-hospital deaths recorded at Oslo University Hospital in 2014 were reviewed by a single physician using a standardized Mortality Analysis form derived from the Institute for Healthcare Improvement’s method of reviewing 50 consecutive deaths. The same reviewer worked through the entire cohort over a period of eight years, an unusually long review window that would later prove scientifically revealing. In addition, a random subset of 20 percent of the cases was independently assessed by a patient safety specialist, allowing the team to measure how consistently two trained professionals judged the same material.

The headline result is sobering but bounded. Of the 1,078 deaths that could be formally reviewed, 32, or three percent, were judged to have had a probability of 50 percent or more of being prevented. In 19 of those cases, an adverse event was considered the direct cause of death, and such events clustered most frequently during or after surgical treatment. Perhaps just as telling is what happened after those deaths were identified: only 12 of the 32 preventable deaths, or 37.5 percent, had ever been reported through the hospital’s own incident reporting system. That gap suggests that formal reporting channels, whatever their administrative value, capture only a fraction of the lethal harm that retrospective review can uncover.

The dual-reviewer exercise exposed the method’s central vulnerability in quantitative terms. In the randomly selected subset assessed by both reviewers, one found 12 preventable deaths, a rate of six percent, while the other found 11, or 5.5 percent. Although those raw numbers appear reassuringly close, the overall interrater agreement was only fair, with a Kappa statistic of 0.4. Kappa corrects for chance agreement, and a value in that range means the two reviewers concurred far less often than the raw counts imply. In practical terms, a case one expert deemed preventable the other frequently did not, a discrepancy that reflects genuine ambiguity in judging counterfactuals: would this patient have survived with different care, or was death imminent regardless?

The most striking finding, however, emerged from the passage of time. Because the same physician reviewed the entire 2014 cohort across four consecutive review periods spanning eight years, the researchers could track whether the reviewer’s own judgments drifted. They did, and dramatically so. The proportion of deaths deemed preventable fell from 5.5 percent in the first review period to 1.0 percent in the last, a statistically significant decline with a p-value below 0.001. Nothing about the care provided in 2014 changed during those eight years; what changed was the person reading the charts. The authors interpret this as evidence that prolonged review work may alter a reviewer’s threshold for what counts as preventable, whether through growing caution, deepening familiarity with the hospital’s routines, or simple fatigue.

That drift has consequences well beyond academic debate. Hospitals and national health authorities increasingly rely on measures such as the Hospital Standardized Mortality Ratio and tools like the Global Trigger Tool to benchmark safety performance, and RCRR-based preventable death estimates feed into programs such as the UK’s Learning from Deaths initiative. If the proportion of deaths judged preventable depends heavily on who reviews the records and when, then comparisons between hospitals, or even within a single hospital over time, may reflect reviewer characteristics more than genuine differences in care quality. The Norwegian team states this conclusion plainly: using RCRR to benchmark preventable deaths may capture reviewer differences more than hospital differences.

The study’s methodology deserves attention for how it balanced rigor with feasibility. The Mortality Analysis form standardized what information the reviewer extracted and how preventability was scored, anchoring judgments to the convention that a death counts as preventable only when the probability reaches at least 50 percent. Reviewing every death rather than a sample eliminated sampling error, and the eight-year single-reviewer design, initially a practical necessity, became an accidental experiment on intra-rater reliability. The project was conducted as a quality assurance initiative under Norwegian law, approved by the hospital’s data protection officer, with data made non-identifiable before analysis and handled in accordance with GDPR and the Declaration of Helsinki.

Placed against the international literature, the three percent figure sits comfortably within the published range. Previous retrospective review studies, from the landmark Harvard Medical Practice Study onward, have produced estimates spanning half a percent to more than eight percent, shaped by differences in case mix, review instruments, reviewer training, and preventability thresholds. The Oslo findings align with the middle of that distribution, which the authors take as evidence that a standardized form can produce results consistent with comparable institutions. Yet the fair interrater agreement and the dramatic intra-rater drift temper any temptation to treat the number as a precise measurement of hospital safety.

For clinicians and policymakers, the study offers a dual message. First, preventable deaths remain a real and measurable problem: three percent of deaths at one of Europe’s largest hospitals, many linked to surgical care, and most never captured by routine incident reporting. Second, the instruments used to count those deaths are less stable than the patient safety movement has often assumed. The authors suggest that RCRR may be better suited to identifying individual cases for learning and improvement than to producing benchmarking statistics that rank institutions. As hospitals worldwide invest in mortality review programs, the Oslo experience stands as a caution: before comparing preventable death rates between hospitals, the field must first solve the harder problem of whether two reviewers, or even one reviewer over time, can agree on what preventable means.

Subject of Research: Preventable in-hospital deaths due to adverse events assessed by retrospective case record review

Article Title: Preventable in-hospital deaths due to adverse events: a retrospective case record review study

Article References: Kaastad, T. S., Tveiten, H., Riiser, T. J., Bukholm, G., & Strand, T.-E. (2026). Preventable in-hospital deaths due to adverse events: a retrospective case record review study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15787-2

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15787-2

Keywords: patient safety, preventable death, in-hospital mortality, retrospective case record review, adverse events, hospital benchmarking, interrater reliability, mortality review, Oslo University Hospital, health services research, incident reporting, quality of care

The urgency behind the guideline is grounded in stark epidemiology. Cigarette smoking remains the leading cause of preventable death in the United States, contributing to hundreds of thousands of deaths each year through lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, and stroke. Smoking rates are not evenly distributed across the population. They are especially high among individuals of lower socioeconomic status, groups that also tend to face greater barriers to accessing outpatient cessation services, and among hospitalized populations, where smoking-related illness is frequently the very reason for admission. For many patients, a hospital stay represents one of the few sustained contacts they will have with the health care system, making it a uniquely valuable window for intervention.

Despite that opportunity, tobacco treatment interventions remain chronically underutilized in hospitals, even though they rank among the most cost-effective strategies in all of health care. Studies of cessation pharmacotherapy and counseling have repeatedly shown favorable cost-effectiveness profiles compared with many other preventive services, yet the practical machinery of inpatient care, with its emphasis on treating the acute presenting illness, often leaves smoking unaddressed. The new guideline aims to close that gap by giving clinicians a clear, standardized protocol rather than leaving cessation decisions to individual habit or institutional variation.

Lead author Hasmeena Kathuria, MD, framed the guideline as a response to that inconsistency. When a patient is hospitalized, she noted, there is a real opportunity to initiate tobacco treatment. Her hope, she said, is that a standardized approach will help more clinicians feel comfortable providing counseling and pharmacotherapy to all hospitalized patients who smoke unless they explicitly decline, and will support continued treatment after discharge. Implementing these approaches, she added, is likely to improve smoking-cessation outcomes and reduce hospital readmissions, a dual benefit that speaks directly to both public health goals and the financial pressures hospitals face under value-based purchasing programs that penalize excess readmissions.

Among the six recommendations, several stand out for their specificity. The guideline recommends that, in hospitalized adults who smoke cigarettes, clinicians initiate varenicline during hospitalization to promote smoking cessation following discharge. Varenicline, a partial agonist at the nicotinic acetylcholine receptor, works by reducing both the reward associated with smoking and the withdrawal symptoms that drive relapse. It has consistently ranked among the most effective single-agent pharmacotherapies for cessation in randomized trials, and starting it in the hospital, rather than waiting for an outpatient visit that may never happen, ensures that patients leave with active treatment already underway.

The guideline also addresses the intensity and continuity of counseling, an area where inpatient practice varies enormously. For hospitalized adults who currently smoke cigarettes, the panel recommends inpatient tobacco treatment counseling lasting fifteen or more minutes over brief advice of less than fifteen minutes. The distinction matters because brief advice, while better than nothing, has modest effect sizes, whereas more substantial counseling sessions allow clinicians to assess dependence, discuss triggers, set quit plans, and address ambivalence using established behavioral techniques such as motivational interviewing. Requiring a minimum duration pushes institutions to allocate real staff time, whether through trained nurses, pharmacists, respiratory therapists, or dedicated cessation counselors, rather than treating a sentence about quitting as sufficient intervention.

Continuity of care forms the third highlighted pillar. The guideline recommends that inpatient counseling for hospitalized adults who smoke include a referral to postdischarge tobacco treatment counseling, with examples including scheduled follow-up contact and direct or electronic health record referral to a quitline or an outpatient program. The postdischarge period is where many inpatient cessation efforts collapse. Withdrawal symptoms intensify as patients return to environments saturated with smoking cues, and without structured follow-up, the momentum built during admission dissipates quickly. Quitlines, which provide free telephone-based coaching and in many jurisdictions medication support, offer a scalable bridge, and electronic health record-based referral systems can automate the connection, reducing the burden on bedside clinicians.

The logic of linking cessation to readmission reduction deserves emphasis. Patients admitted with exacerbations of COPD, acute coronary syndromes, pneumonia, or heart failure who continue smoking face elevated risks of returning to the hospital, and smoking cessation after such diagnoses measurably improves survival and reduces recurrent events. By embedding cessation into the inpatient workflow, hospitals can address a modifiable risk factor at the moment of maximal patient receptivity. The guideline’s authors argue that a standardized approach, applied to every hospitalized patient who smokes unless the patient explicitly declines, transforms cessation from an optional add-on into a default standard of care, analogous to venous thromboembolism prophylaxis or medication reconciliation.

The full set of six recommendations, including those not highlighted in the release, is available through the CHEST journal website in the article titled Tobacco Treatment in the Inpatient Setting: An American College of Chest Physicians Clinical Practice Guideline. As with other CHEST clinical practice guidelines, the recommendations synthesize the available literature using structured methodology, grading both the quality of evidence and the strength of each recommendation so that clinicians can understand how firmly each statement is supported. Guideline panels of this kind typically weigh randomized trial data, observational evidence, and patient values and preferences, and the published document details the rationale behind each recommendation for readers who need to adapt the guidance to local resources and populations.

For hospitals and health systems, the practical implications are significant. Implementing the guideline will require mechanisms to identify every admitted patient who smokes, typically through admission screening embedded in the electronic health record; protocols to prescribe varenicline where clinically appropriate, with attention to contraindications and drug interactions; staffing or consult services capable of delivering counseling sessions of at least fifteen minutes; and referral pathways that reliably connect patients to quitlines or outpatient programs before discharge. None of these components is technically difficult, but each requires institutional commitment, and the guideline’s standardization is intended to make that commitment easier to justify and audit. For the roughly one in eight American adults who smoke, many of whom will pass through a hospital bed in any given year, the guideline converts a fleeting admission into a structured pathway toward quitting, one that begins at the bedside and continues long after discharge.

Subject of Research: Evidence-based tobacco treatment recommendations for hospitalized adult patients

Article Title: CHEST releases guideline on tobacco treatment in the inpatient setting

Article References: CHEST releases guideline on tobacco treatment in the inpatient setting. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: tobacco treatment, smoking cessation, hospitalized patients, clinical practice guideline, varenicline, counseling, quitline, hospital readmissions, American College of Chest Physicians, inpatient care, preventable death, postdischarge follow-up