Matsumoto Shokei, Jung Kyoungwon, Smith Alan, Coimbra Raul
Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego, 200 W. Arbor Drive, San Diego, CA, 92103-8896, USA.
Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
Surg Today. 2018 Nov;48(11):1004-1010. doi: 10.1007/s00595-018-1687-y. Epub 2018 Jun 23.
To establish the preventable and potentially preventable death rates in a mature trauma center and to identify the causes of death and highlight the lessons learned from these cases.
We analyzed data from a Level-1 Trauma Center Registry, collected over a 15-year period. Data on demographics, timing of death, and potential errors were collected. Deaths were judged as preventable (PD), potentially preventable (PPD), or non-preventable (NPD), following a strict external peer-review process.
During the 15-year period, there were 874 deaths, 15 (1.7%) and 6 (0.7%) of which were considered PPDs and PDs, respectively. Patients in the PD and PPD groups were not sicker and had less severe head injury than those in the NPD group. The time-death distribution differed according to preventability. We identified 21 errors in the PD and PPD groups, but only 61 (7.3%) errors in the NPD group (n = 853). Errors in judgement accounted for the majority and for 90.5% of the PD and PPD group errors.
Although the numbers of PDs and PPDs were low, denoting maturity of our trauma center, there are important lessons to be learned about how errors in judgment led to deaths that could have been prevented.
确定一家成熟创伤中心的可预防和潜在可预防死亡率，找出死亡原因，并突出从这些病例中吸取的教训。
我们分析了从一级创伤中心登记处收集的、为期15年的数据。收集了人口统计学、死亡时间和潜在错误的数据。经过严格的外部同行评审过程，将死亡判定为可预防（PD）、潜在可预防（PPD）或不可预防（NPD）。
在这15年期间，共有874例死亡，其中分别有15例（1.7%）和6例（0.7%）被认为是PPD和PD。与NPD组相比，PD组和PPD组的患者病情较轻，头部损伤也较轻。根据可预防性，死亡时间分布有所不同。我们在PD组和PPD组中发现了21处错误，但在NPD组（n = 853）中仅发现61处（7.3%）错误。判断错误占大多数，占PD组和PPD组错误的90.5%。
尽管PD和PPD的数量较少，表明我们的创伤中心已经成熟，但关于判断错误如何导致本可预防的死亡，仍有重要的教训需要吸取。
