Management deficiencies and death preventability in 120 victorian road fatalities (1993-1994). the Consultative Committee on Road Traffic Fatalities in Victoria

McDermott, F. T.; Cordner, Stephen M.; Tremayne, A. B.

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Management deficiencies and death preventability in 120 victorian road fatalities (1993-1994). the Consultative Committee on Road Traffic Fatalities in Victoria
Citation	McDermott FT, Cordner SM, Tremayne AB. Aust. N. Zeal. J. Surg. 1997; 67(9): 611-618.
Affiliation	Department of Surgery, Monash University, Alfred Healthcare Group, Alfred Hospital, Prahran, Victoria, Australia.
Copyright	(Copyright © 1997, John Wiley and Sons)
DOI	unavailable
PMID	9322697
Abstract	BACKGROUND: In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: survival probability between 25 and 75%). METHODS: For 1993-94, 120 consecutive fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete pre-hospital, hospital and autopsy records. RESULTS: A total of 1175 problems were identified in 455 admission to the various areas of care. A total of 949 problems (81%) were found to be management errors and 123 (11%) were found to be system inadequacies. Technique errors (35 (3%)), diagnosis delays (27 (2%)) and diagnosis errors (41 (4%)) were less frequent. The emergency department (ED) accounted for 662 (56%) problems, followed by 191 (16%) pre-hospital problems and 140 (12%) intensive care unit (ICU) problems. There were 598 (51%) problems that were assessed as contributing to death. A total of 308 (52%) problems occurred in the ED, 106 (18%) were pre-hospital problems and 71 (12%) occurred in ICU. Management errors comprised 465 (78%) problems contributing to death, and system inadequacies comprised 76 (13%) problems. Resuscitation problems accounted for 101 (40%) of the 254 ED management errors contributing to death. A total of 79 (66%) deaths were assessed as non-preventable, five (4%) were assessed as preventable and 36 (30%) were assessed as potentially preventable. CONCLUSIONS: Organization and educational countermeasures are required to reduce the high frequency of problems in emergency services and clinical management.