TIME FOR A CHANGE IN INJURY AND TRAUMA CARE DELIVERY: A TRAUMA DEATH REVIEW ANALYSIS

摘要: Safety and error reduction in medical care is crucial to the future of medicine. This study evaluates trauma patients dying at a level 1 centre determine adequacy care. All deaths between 1996 2003 were reviewed by an eight-member multidisciplinary death review panel. Errors classified according their location, nature, impact, outcome whether avoidable or non-avoidable. Avoidable categorized as potentially, probably definitely avoidable. Between 2003, there 17 157 admissions, including 307 deaths. The mean patient age was 47.7 years ± 24.8 years, injury severity score 38.1 ± 19.6. Of all deaths, 69 (22.5%) deemed 61 (88%) potentially avoidable, 7 (10%) (1.4%) associated with increased age, lower score, admissions intensive unit, longer hospital stay treatment non-trauma surgeon (P < 0.05). 271 (89.3%) experienced total 1063 errors, overall rate 3.5 per patient. non-avoidable group 2.9 5.3 (P < 0.0001). Most errors occurred resuscitation area. Age, injury, length are factors A new approach required.