title: Preventable or potentially preventable mortality at a mature trauma center.
abstract: OBJECTIVE
  The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center.
  
  
  METHODS
  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 individual chart review.
  
  
  RESULTS
  During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%).
  
  
  CONCLUSIONS
  Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.
authors.affiliation: Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, California, USA.
authors.forename: Pedro G R
authors.initials: PG
authors.lastname: Teixeira
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Pantelis
authors.initials: P
authors.lastname: Hadjizacharia
authors.forename: Carlos
authors.initials: C
authors.lastname: Brown
authors.forename: Ali
authors.initials: A
authors.lastname: Salim
authors.forename: Peter
authors.initials: P
authors.lastname: Rhee
authors.forename: Timothy
authors.initials: T
authors.lastname: Browder
authors.forename: Thomas T
authors.initials: TT
authors.lastname: Noguchi
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000328:Adult; D002423:Cause of Death; D003951:Diagnostic Errors; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D015141:Los Angeles; D008297:Male; D011785:Quality Assurance, Health Care; D012042:Registries; D013997:Time Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014949:Wounds, Nonpenetrating / Q000145:classification / Q000401:mortality* / Q000628:therapy