title: Preventable deaths in patients with traumatic brain injury.
abstract: OBJECTIVE
  The objective of this study is to evaluate the rate of and etiology for preventable deaths in patients with traumatic brain injuries (TBIs).
  
  
  METHODS
  We conducted a retrospective, multicenter review of patients with TBIs who died within 7 days of their traumatic event from June 2008 to May 2009. Three board certified emergency physicians independently reviewed every case using a structured survey format. Cases were considered preventable deaths only if all physicians independently agreed the death was preventable. Management errors contributing to the preventable death were determined.
  
  
  RESULTS
  Forty-one patients who died from TBI were eligible. Preventable deaths were identified in nine (22%; 95% confidence interval [CI], 11 to 28) cases. Fifty-six management errors were identified including 36 (64%; 95% CI, 50 to 77) in the emergency department and 13 (23%; 95% CI, 13 to 36) in the prehospital phase. Thirty (54%; 95% CI, 40 to 67) management errors were process-related, and 26 (46%; 95% CI, 33 to 60) were structure-related.
  
  
  CONCLUSIONS
  An important and measurable rate of preventable mortality occurs in the initial care of TBI patients. Errors were common and most occurred in the emergency department. In addition, errors were common in the prehospital phase but did not always lead to mortality. When analyzed by type of problem, both process-related and structure-related errors occurred in similar proportions.
authors.affiliation: Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Korea.
authors.forename: Seong Chun
authors.initials: SC
authors.lastname: Kim
authors.affiliation: Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Kyoung Jun
authors.initials: KJ
authors.lastname: Song
authors.affiliation: Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Sang Do
authors.initials: SD
authors.lastname: Shin
authors.affiliation: Department of Emergency Medicine, Dongkuk University College of Medicine, Ilsan, Korea.
authors.forename: Seung Chul
authors.initials: SC
authors.lastname: Lee
authors.affiliation: Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Ju Ok
authors.initials: JO
authors.lastname: Park
authors.affiliation: Department of Emergency Medicine, UC Davis Medical Center (JFH), Davis, CA, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Holmes
keywords: Brain injury; Death; Errors; Process; Structure