Preventability Of Death Research Articles

Dead men tell no tales

To analyze the influence and use of autopsy report review on preventability judgments as part of trauma system performance improvement activities. All cases trauma fatalities occurring across one state within 1 year were reviewed. Preventability judgments were first analyzed by multidisciplinary panel consensus without benefit of autopsy report. Deaths were then reanalyzed after the panel was provided with autopsy findings. Changes in panel determinations of preventability and cause of death were noted. A total of 434 cases were reviewed, autopsies were performed in 240 (55%) patients. Autopsy rate was 83% for prehospital deaths (PHDs) and 37% for hospital deaths (HDs). A complete examination (CA) was performed in 166 (69%) cases, and 74 (31%) cases were limited internal or external examinations only (NCA). Of autopsies performed on HD, 60% were CA versus 75% in PHD. Autopsy review changed preventability determination in four cases (1%). All changes were from nonpreventable to possibly preventable. For all patients with autopsy, the panel felt that the autopsy should have been of sufficient quality to analyze the cause of death in 83%. The autopsy was felt to actually establish a specific cause of death in 70% of all patients with autopsy, 71% in patients with NCA, and 74% in patients with CA. The autopsy changed the panel's preautopsy review-determination cause of death in 31% of all patients with autopsy (37% in the CA group; 13% in the NCA group). For PHD, autopsy changed the panel-determination cause of death in 44% and in 13% for HD. Review of autopsy reports adds little to the trauma performance improvement process. It does not significantly change death review panel determinations. It may, perhaps, be most useful in PHD. Ardent initiatives to expend resources on autopsy performance and acquisition of autopsy reports in all patients with trauma is unwarranted.

Eliminating Preventable, Hemorrhage‐Related Maternal Mortality and Morbidity

Debra Bingham, DrPH, RN, is the Vice President of Research, Education, and Publications for the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Washington, DC. An assumption exists that any woman who gives birth in any hospital in the United States will have access to blood products and other, basic, life-saving therapies and that these hospitals will have an adequate number of highly skilled clinicians (nurses, doctors, midwifes) who can reliably recognize, respond, and manage an obstetric hemorrhage. However, these assumptions have been called into question by multiple researchers who studied the preventability of obstetric hemorrhage-related deaths. In these studies, researchers reported that 54% (Della Torre et al., 2011), 70% (California Department of Public Health, 2011), or even 93% (Berg et al., 2005) of the obstetric hemorrhage-related mortality cases reviewed were judged to be preventable. These researchers found that clinician error was the major factor contributing to maternal deaths. Another very troubling statistic is the overall 3-fold to 4fold racial disparity in maternal mortality. Researchers from the Centers for Disease Control and Prevention (CDC) showed that Black women were equally as likely as White women to have an obstetric hemorrhage, but in women experiencing an obstetric hemorrhage, Black women were 2 to 3 times more likely to die than White women (Tucker, Berg, Callaghan, & Hsia, 2007).

Cause and Circumstance of In-Hospital Mortality Among Patients Undergoing Contemporary Percutaneous Coronary Intervention

Prior studies suggest that most deaths in patients undergoing percutaneous coronary intervention (PCI) are related to procedural complications. Mortality associated with PCI has steadily declined during the past decade, and the cause and circumstance of death among patients undergoing PCI in the contemporary era remain unknown. We evaluated all patients undergoing PCI at the University of Michigan from 2001 to 2009. There were 85 deaths among a total of 5520 patients undergoing PCI during this time period. By using a standardized data collection form, 3 cardiologists (2 interventional, H.S.G. and D.S.M.; 1 noninvasive, A.M.B.) determined the cause and circumstance of death, in addition to grading the preventability of death. Left ventricular failure was the most common cause of death (35.3%, n=30), followed by neurological compromise (16.5%, n=14) and arrhythmia (12.1%, n=12). The circumstance of death was mostly acute cardiac (52.9%, n=45), with a procedural complication composing a small fraction (7.1%, n=6). Reviewers determined 93% of deaths to be mostly or entirely unpreventable. Procedural complications are responsible for a small fraction of deaths among patients undergoing contemporary PCI. Measures to further enhance procedural safety are unlikely to translate into meaningful reductions in PCI mortality.

803: Preventability of pregnancy-related deaths from preeclampsia and eclampsia in Florida, 1999-2008

803: Preventability of pregnancy-related deaths from preeclampsia and eclampsia in Florida, 1999-2008

Child Fatality Review

This Policy Statement was revised. See https://doi.org/10.1542/peds.2023-065481. Injury remains the leading cause of pediatric mortality and requires public health approaches to reduce preventable deaths. Child fatality review teams, first established to review suspicious child deaths involving abuse or neglect, have expanded toward a public health model of prevention of child fatality through systematic review of child deaths from birth through adolescence. Approximately half of all states report reviewing child deaths from all causes, and the process of fatality review has identified effective local and state prevention strategies for reducing child deaths. This expanded approach can be a powerful tool in understanding the epidemiology and preventability of child death locally, regionally, and nationally; improving accuracy of vital statistics data; and identifying public health and legislative strategies for reducing preventable child fatalities. The American Academy of Pediatrics supports the development of federal and state legislation to enhance the child fatality review process and recommends that pediatricians become involved in local and state child death reviews.

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.

Preventability of trauma deaths in a Dutch Level-1 trauma centre

Background Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability. Methods All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus. Results Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. Conclusions The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.

Is there benefit in implanting defibrillators in patients with severe heart failure?

BackgroundIt is current practice to withhold implantable cardioverter defibrillators (ICD) from patients with severe heart failure because their deaths are judged as non-sudden and therefore assumed not to be preventable...

Acts of Resistance: Breaking the Silence of Grief Following Traffic Crash Fatalities

Theoretical arguments and empirical evidence demonstrate the limited utility of a narrow construction of “normal” grief. Sudden and violent death, the young age of the deceased, and perceptions of death preventability are associated with grief reactions that extend beyond an expected grief response. Interviews were conducted with 21 adults bereaved through the death of a family member in a traffic crash. We present their attempts to resist notions of “working through” grief and “recovery” from it and consider how the participants' constructions of an alternative discourse, or normative narrative, possess the potential to challenge a prevailing grief discourse.

Maternal mortality in Syria: causes, contributing factors and preventability

To describe the biomedical and other causes of maternal death in Syria and to assess their preventability. A reproductive age mortality study (RAMOS) design was used to identify pregnancy related deaths. All deaths among women aged 15-49 reported to the national civil register for 2003 were investigated through home interviews. Verbal autopsies were used to ascertain the cause of death among pregnancy related maternal deaths, and causes and preventability of deaths were assessed by a panel of doctors. A total of 129 maternal deaths were identified and reviewed. Direct medical causes accounted for 88%, and haemorrhage was the main cause of death (65%). Sixty nine deaths (54%) occurred during labour or delivery. Poor clinical skills and lack of clinical competency were behind 54% of maternal deaths. Ninety one percent of maternal deaths were preventable. The causes of maternal death in Syria and their contributing factors reflect serious defects in the quality of maternal care that need to be urgently rectified.

Preventing Child Deaths

Preventing Child Deaths

Public Reporting of 30-Day Mortality for Patients Hospitalized With Acute Myocardial Infarction and Heart Failure

For cardiac care, the Centers for Medicare M how often smokers are counseled to quit; how rapidly hospitals provide reperfusion therapy for patients with an ST-segment elevation myocardial infarction; and how often the ejection fraction is measured for patients with heart failure. All of these measures assess care that is strongly recommended by guidelines. The measures include only those patients who should receive this care and are reported at the hospital level simply as percentages. The performance on these measures should ideally be 100%, and the rates have improved markedly over time. ; View this table: Table. Acute Myocardial Infarction and Heart Failure Process-of-Care Measures On June 21, 2007, CMS expanded the measures to include outcomes and posted information on its “Hospital Compare” website1 regarding hospital-specific 30-day mortality rates for patients with acute myocardial infarction and heart failure. These measures used administrative claims data and were validated against measures using medical record data; the measures were approved by the National Quality Forum.2,3 In 2007, the publicly reported information was limited to describing hospitals as having rates that were higher, lower, or no different than the national average. Hospitals received information about their rates, their patients, and comparisons with other hospitals in their state and with the nation. This year, CMS is expanding the publicly available information. For acute myocardial infarction, heart failure, and now pneumonia, CMS will post the calculated risk-standardized 30-day mortality rates (RSMRs) and the 95% interval estimates for each hospital that treated Medicare patients with these conditions; hospital volume for each condition also will be posted. As …

Mortalidade infantil e evitabilidade em Mato Grosso do Sul, Brasil, 2000 a 2002

This retrospective study describes the epidemiological profile of infant mortality in 2000-2002 in 16 counties in Mato Grosso do Sul State, Brazil, and evaluates the preventability of such deaths, using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the List of Causes of Death Preventable by Interventions in the Setting of the Brazilian Unified National Health System in Children Under Five Years. Perinatal causes accounted for 54.3% of the 1,537 deaths, according to the Mortality Information System; congenital anomalies 14.9%; infectious and parasitic diseases 9.4%; and respiratory disorders 7%. A full 73.1% of deaths were preventable, and most (69.5%) resulted from inadequate prenatal, obstetric, and neonatal care. Additional causes were related to vaccine prevention (0.7%), diagnosis and treatment (10.4%), and health promotion (11.2%). Causes not entirely avoidable accounted for 24.3% of deaths. The findings emphasize the relevance of monitoring adverse maternal-infant conditions and events, particularly to reduce early neonatal mortality (<7 days of life).

Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates

The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level. We conducted a retrospective analysis of 347 randomly selected in-hospital deaths after isolated coronary artery bypass graft surgery at 9 institutions in Ontario over the period of 1998 to 2003. Nurse-abstracted chart summaries were reviewed by 2 experienced cardiac surgeons who were blinded to patient, surgeon, and hospital and used a standardized implicit tool to identify preventable death. A third reviewer reassessed all cases in which the first 2 reviewers disagreed. Rates of preventable deaths were estimated for each hospital and compared with all-cause mortality rates. A structured adverse event audit completed by each surgeon-reviewer was used to identify quality improvement opportunities for the preventable deaths. A total of 111 of 347 deaths (32%) were judged preventable despite a low risk-adjusted mortality range (1.3% to 3.1%) across hospitals. No significant correlation was found between all-cause, risk-adjusted in-hospital mortality rates and the proportion of preventable deaths at the hospital level (Spearman coefficient, -0.42; P=0.26). A large proportion of preventable deaths were related to problems in the operating room (86%) and intensive care unit (61%). Many deaths were associated with deviations in perioperative care (32% based on concurrence of 2 reviewers, and another 42% in cases in which 1 reviewer reached that opinion). Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.

Clinical Summaries

Clinical Summaries

Seeking Better Outcomes in Coronary Artery Bypass Grafting

Are we delivering the safest and most effective care? How best can we learn from our experience? For healthcare professionals who ask these questions, the article by Guru and colleagues in this issue of Circulation is essential reading.1 These Canadian investigators performed an implicit review and retrospective analysis of 347 randomly selected in-hospital deaths after coronary artery bypass grafting (CABG) surgery and determined that approximately one third might have been prevented by better care. The study offers many important lessons with implications far beyond cardiac surgery. Article p 2969 Guru and colleagues uncovered many opportunities for important improvements in a hospital system that could have been content with its successes. Their investigation was conducted in a system with no low-volume hospitals and low risk-adjusted mortality rates and involved the participation of experienced staff surgeons and division chiefs. They found remarkably high percentages of preventable deaths, defined as deaths that could have been avoided had optimal care been delivered. Optimal care was considered to be the best possible care that could be delivered if current resources were operating at peak performance in accordance with the best available evidence at the time of the hospital admission. The investigators found that as many as 107 preventable CABG-related deaths occurred in Ontario in fiscal year 2000 to 2001. These deaths occurred in every institution. In particular, the highest percentages of preventable deaths were not clustered at the institutions with the highest risk-adjusted mortality rates, indicating that even a low mortality rate should not beget complacency. Even in the hospital with the lowest risk-adjusted mortality rate, about 20% of deaths were deemed to be preventable. Guru and colleagues focused specifically on contributing causes of deaths that may have been prevented. In this way, many deaths had more than 1 potential contributing cause. In each …

Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery

We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined. Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

Management Deficiencies and Death Preventability of Road Traffic Fatalities Before and After a New Trauma Care System in Victoria, Australia

The Consultative Committee's findings that preventable or potentially preventable (P/PP) death rates (survival prospects > or =25%) of road crash fatalities who received treatment were unaltered between 1992 and 1998 led to a Ministerial Taskforce on Trauma and the gradual introduction of a new Victorian trauma care system. The present study compares outcomes before (1997-1998) and after (2002-2004) the new system. The emergency and clinical management and death preventability of 245 consecutive fatalities in the 'before' period and 193 in the 'after' period was assessed by the committee's multidisciplinary panels using the complete hospital, ambulance, and autopsy findings. Emergency department admissions to expanded Major Trauma Services (MTS) increased from 34% to 62% (p < 0.05). More patients were attended by Advanced Trauma Life Support paramedics (p < 0.05) and scene times increased (p < 0.05). Patients admitted within 1 hour decreased from 70% to 45% (p < 0.05). The mean number of deficiencies per patient including those contributing to death was decreased (p < 0.05). The combined P/PP death rates decreased from 36% to 28% (22% relative risk reduction). The P/PP death rates for MTS, Metropolitan Trauma Services, Rural Trauma Services, and Urgent Care Centers for 2002 to 2004 were 25%, 33%, 50%, and 83%, respectively, and did not differ significantly from those of 1997 to 1998 (23%, 49%, 36%, 75%, respectively). The P/PP death rates in MTS were less than those of the other hospital groups. The new Victorian trauma care system has resulted in a significant decrease in deficiencies including those contributing to death and a decrease in P/PP deaths rates. The improvement has been largely consequent to a marked increase in admissions to MTS.

Preventability of Pregnancy-Related Deaths

Preventability of Pregnancy-Related Deaths

Preventability of Pregnancy-Related Deaths

Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced. The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented. Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women. Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.