Preventable or potentially preventable mortality at a mature trauma center

The Journal of Trauma
Pedro G R TeixeiraDemetrios Demetriades

Abstract

The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center. All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and ind...Continue Reading

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