Potentially preventable deaths in a medium sized community hospital

INTRODUCTION: The purpose of this study was to estimate the occurrence and causes of potentially preventable deaths at a medium sized community hospital. MATERIALS AND METHODS: A review of a consecutive series of records of 48 deceased patients (age 58-98 years, median 81 years, 40% males) was conducted by four observers, followed by a consensus conference in which the deaths were classified as potentially preventable according to a checklist, focusing on the occurrence of adverse events or failure to comply with evidence-based procedures. RESULTS: 10 of the 48 deaths were considered potentially preventable; in two cases the potential was considered significant, but the age and underlying diseases of the patients suggest that the potential number of saved life years is modest. The main reasons for preventability were unintended delays, ineffective treatment plans, and lack of reactions to new and important diagnostic information. CONCLUSION: The review of the deaths revealed a considerable number of potentially preventable cases. Furthermore, a number of suggestions for improvement were identified: (1) early identification and aggressive treatment of impending sepsis; (2) employment of routines to ensure that new diagnostic information is reviewed and acted upon and (3) systematic updating of competences in all staff members.