Hakkenbrak et al review preventable deaths in trauma patients. The authors are from Amsterdam University Medical Centre, Vrije Universiteit Amsterdam and the Public Health Service of Amsterdam.

Situation: death of a trauma patient




trauma-related preventable death

death could have been prevented by timely implementation of standard practice OR avoidable error OR suboptimal care

trauma-related potentially preventable death

death could have been avoided with optimal care; care appropriate overall but some deviations could have contributed to death

trauma-related non-preventable death

death unavoidable despite adequate care and appropriate evaluation AND/OR comorbid condition as major contributor to death


Additional factors:

(1) a complete and thorough autopsy is required to identify any contributory factors

(2) TRISS or other score can be used to predict the expected probability of survival

(3) the case should be reviewed with input from a trauma surgeon, ED doctor, anesthesiologist and forensic pathologist

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