Preventability of trauma deaths in a Dutch Level-1 trauma centre.
BACKGROUND
Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability.


METHODS
All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus.


RESULTS
Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies.


CONCLUSIONS
The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.
Saltzherr
T P
TP
Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. t.p.saltzherr@amc.nl
Wendt
K W
KW
Nieboer
P
P
Nijsten
M W N
MW
Valk
J P
JP
Luitse
J S K
JS
Ponsen
K J
KJ
Goslings
J C
JC
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D002648:Child; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D010043:Outcome and Process Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000458:organization & administration / Q000706:statistics & numerical data*; D014947:Wounds and Injuries / Q000401:mortality* / Q000517:prevention & control / Q000628:therapy; D055815:Young Adult