title: Management deficiencies and death preventability in 120 Victorian road fatalities (1993-1994). The Consultative Committee on Road Traffic Fatalities in Victoria.
abstract: BACKGROUND
  In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: survival probability between 25 and 75%).
  
  
  METHODS
  For 1993-94, 120 consecutive fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete pre-hospital, hospital and autopsy records.
  
  
  RESULTS
  A total of 1175 problems were identified in 455 admission to the various areas of care. A total of 949 problems (81%) were found to be management errors and 123 (11%) were found to be system inadequacies. Technique errors (35 (3%)), diagnosis delays (27 (2%)) and diagnosis errors (41 (4%)) were less frequent. The emergency department (ED) accounted for 662 (56%) problems, followed by 191 (16%) pre-hospital problems and 140 (12%) intensive care unit (ICU) problems. There were 598 (51%) problems that were assessed as contributing to death. A total of 308 (52%) problems occurred in the ED, 106 (18%) were pre-hospital problems and 71 (12%) occurred in ICU. Management errors comprised 465 (78%) problems contributing to death, and system inadequacies comprised 76 (13%) problems. Resuscitation problems accounted for 101 (40%) of the 254 ED management errors contributing to death. A total of 79 (66%) deaths were assessed as non-preventable, five (4%) were assessed as preventable and 36 (30%) were assessed as potentially preventable.
  
  
  CONCLUSIONS
  Organization and educational countermeasures are required to reduce the high frequency of problems in emergency services and clinical management.
authors.affiliation: Department of Surgery, Monash University, Alfred Healthcare Group, Alfred Hospital, Prahran, Victoria, Australia.
authors.forename: F T
authors.initials: FT
authors.lastname: McDermott
authors.forename: S M
authors.initials: SM
authors.lastname: Cordner
authors.forename: A B
authors.initials: AB
authors.lastname: Tremayne
mesh_terms: D000063:Accidents, Traffic / Q000401:mortality* / Q000517:prevention & control*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003951:Diagnostic Errors; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D018024:Peer Review, Health Care; D011787:Quality of Health Care; D016019:Survival Analysis; D013997:Time Factors; D014739:Victoria / Q000453:epidemiology