The judgment about preventability depends on a number of issues:
(1) was a life-preserving drug, test or treatment available at the facility?
(2) was critical information withheld from the clinicians?
(3) was a clinician with adequate expertise available?
(4) was the assessment adequate and comprehensive?
Preventable causes of unexpected death may include:
(1) failure to diagnose sepsis
(2) failure to diagnose ischemic heart disease
(3) failure to diagnose intra-cranial pathology (subdural hematoma after trauma, etc)
(4) failure to diagnose or misdiagnosis of other life-threatening conditions
(5) discharge from the ED (failure to admit)
(6) failure to triage properly (to the ICU, other)
(7) failure to order or delay in performing appropriate testing
(8) failure to properly manage a drug overdose
(9) failure to monitor a cardiac pacemaker
(10) failure to detect occult hemorrhage following trauma
(11) failure to adequately monitor vital signs
(12) leaving someone unattended who should have had an attendant
(13) insufficient or excessive fluid resuscitation
(14) failure to adequately treat
(15) failure to give the appropriate dose of a drug
(16) giving a drug to which the patient is known to be allergic
(17) failure to recognize abuse
