Clinical ScienceClassifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology
Section snippets
Study setting
The Trauma Center at Penn is a level-I trauma center accredited by the Pennsylvania Trauma Systems Foundation (PTSF), the sole accrediting authority of trauma centers in the state of Pennsylvania. The Trauma Center at Penn is based at the Hospital of the University of Pennsylvania (HUP), an academic tertiary care medical center in Philadelphia, Pennsylvania. The trauma service evaluates all patients meeting field triage criteria for trauma as established by the state bureau of Emergency Medical
Patient population and demographics
Annual trauma visits in the study time period ranged from 2,253 to 3,162 with a mean of 2,708 trauma contacts per year. A total of 11,100 trauma patient admissions were identified in the registry in the specified time period, of which 1,377 (12.4%) in-hospital deaths were reported. Of these, 18 (1.3% of all deaths, .16% of all trauma admissions) were classified as preventable, 88 (6.4% of all deaths, .79% of all trauma admissions) as potentially preventable, and 1,271 (92.3% of all deaths,
Comments
Depending on definitions used in published reports, the incidence of preventable death in trauma ranges from 2% to 29%.4, 15, 23, 24 Determining preventability of death depends on the identification of avoidable errors in the management of injured patients during their hospital care and sometimes also their prehospital care. In a 9-year review, we found a 7% incidence of preventable and potentially preventable deaths in our urban academic trauma center. We classified 142 avoidable errors
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