Preventable deaths and potentially preventable deaths. What are our errors?

Area of Science:

• Medical research
• Trauma care systems
• Patient safety

Background:

• Lack of standardized systems for identifying and addressing errors in multiple trauma patient management.
• Need for a universal language to classify patient safety incidents.

Purpose of the Study:

• Detect preventable and potentially preventable deaths in trauma patients.
• Classify all management errors using a standardized, universal language.

Main Methods:

• Studied trauma patients over 16 admitted to critical care or who died.
• Multidisciplinary sessions to determine preventability of deaths.
• Classified management errors using the Joint Commission taxonomy and ATLS protocols.

Main Results:

• 19 of 115 trauma deaths were preventable or potentially preventable.
• 130 errors recorded in total deaths; 46 in preventable/potentially preventable deaths.
• Main errors included delayed treatment and CT scans in unstable patients; human failure ('rule-based' errors) was the primary cause.

Conclusions:

• Measuring and recording results is key to improving trauma patient care quality.
• A common language, such as the Joint Commission taxonomy, standardizes patient safety data.
• Standardization improves incident recording, analysis, and treatment for better patient outcomes.