Unexpected Death on the Non‐ICU Trauma Ward
作者:
GARY KUBALAK,
MICHAEL RHODES,
DEBORAH BOORSE,
LOUIS D'AMELIO,
期刊:
The Journal of Trauma: Injury, Infection, and Critical Care
(OVID Available online 1991)
卷期:
Volume 31,
issue 9
页码: 1258-1264
ISSN:0022-5282
年代: 1991
出版商: OVID
数据来源: OVID
摘要:
To characterize trauma patients who die unexpectedly on the ward (unexpected ward deaths = UWDs), 1,011 trauma-related deaths occurring at a level I trauma center over a 10-year period were reviewed for location of death. Seventy-four deaths occurred on the non-ICU trauma ward (i.e., nonmonitored med-surg floor). Fifty patients were “do not resuscitate” (expected deaths). Twenty-four patients (mean age, 58.0 years) died unexpectedly (2.4% of trauma-related deaths). The majority had a central nervous system injury or a precipitating event that occurred at night. Twelve (50%) of the UWDs were determined by peer review to be potentially preventable and were the result of delayed diagnosis (n = 6), aspiration (n = 3), or cardiorespiratory arrest (n = 3). We conclude that unexpected trauma center deaths related to events occurring on the non-ICU trauma ward (2.4% of trauma deaths) occur mostly at night in older, neurologically impaired patients and that half of these deaths may be potentially preventable. Increased awareness of this issue and an environment for direct patient observation may reduce the number of these potentially preventable deaths.
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