title: Preventable deaths and potentially preventable deaths. What are our errors?
abstract: BACKGROUND
  A variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem.
  
  
  OBJECTIVE
  Detect preventable and potentially preventable deaths, and classify all the errors with universal language.
  
  
  METHODS
  We studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission.
  
  
  RESULTS
  We registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths. Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients. Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically 'rule-based' errors
  
  
  CONCLUSIONS
  Measuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.
authors.affiliation: General Surgery, Hospital Universitari Parc Taulí, C. Sant Llorenç, 14-1r1a, 08202 Sabadell, Spain. Electronic address: sandra.montmany@gmail.com.
authors.forename: Sandra
authors.initials: S
authors.lastname: Montmany
authors.affiliation: General Surgery, Fundación Hospital Son Llàtzer, Carretera de Manacor, 4, 07198 Son Ferriol, Islas Baleares, Spain. Electronic address: apallill@gmail.com.
authors.forename: Anna
authors.initials: A
authors.lastname: Pallisera
authors.affiliation: General Surgery, Hospital Universitari Parc Taulí, Parc Taulí, s/n, 08208 Sabadell, Spain. Electronic address: prebasa@tauli.cat.
authors.forename: Pere
authors.initials: P
authors.lastname: Rebasa
authors.affiliation: General Surgery, Hospital Universitari Parc Taulí, Parc Taulí, s/n, 08208 Sabadell, Spain. Electronic address: acampos@tauli.cat.
authors.forename: Andrea
authors.initials: A
authors.lastname: Campos
authors.affiliation: Anesthesiology, Hospital Universitari Parc Taulí, Parc Taulí, s/n, 08208 Sabadell, Spain. Electronic address: ccolilles@tauli.cat.
authors.forename: Carme
authors.initials: C
authors.lastname: Colilles
authors.affiliation: General Surgery, Hospital Universitari Parc Taulí, Parc Taulí, s/n, 08208 Sabadell, Spain. Electronic address: aluna@tauli.cat.
authors.forename: Alexis
authors.initials: A
authors.lastname: Luna
authors.affiliation: General Surgery, Hospital Universitari Parc Taulí, Parc Taulí, s/n, 08208 Sabadell, Spain. Electronic address: snavarro@tauli.cat.
authors.forename: Salvador
authors.initials: S
authors.lastname: Navarro
mesh_terms: D002423:Cause of Death; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000401:mortality* / Q000517:prevention & control / Q000706:statistics & numerical data; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control; D017063:Outcome Assessment, Health Care; D011785:Quality Assurance, Health Care; D012042:Registries; D012189:Retrospective Studies; D012769:Shock / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000150:complications / Q000401:mortality* / Q000503:physiopathology
keywords: Errors; Joint Commission; Preventable deaths; Trauma patients