Preventable deaths and potentially preventable deaths. What are our errors?. Issue 3 (March 2016) - Montmany, Sandra
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. Objectives: 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.