Evaluation of autopsy reports in terms of preventability of traumatic deaths

Abstract

Background: The analysis of autopsy reports plays an important role in the evaluation of trauma care quality. The objective of this study was to determine the rate of preventable deaths and medical errors in regard to the autopsy reports as an indicator of trauma care quality in traumatic deaths.

Methods: A retrospective review of traumatic autopsy reports kept between 2011 and 2012 in Eskişehir, Turkey was conducted. Demographic data of the cases, injury type, injury mechanism, injury location, ISS values, and cause and place of death were recorded. Deaths were judged in three groups including preventable deaths, potentially preventable deaths and non-preventable deaths. In the definiton of preventability, the criteria of American College of Surgeons Committee on Trauma were used. A commission composed of two forensic medicine specialists and one emergency medicine specialist reviewed preventability and defined medical errors.

Results: A total of five hundred and ninety-two autopsy reports were examined in the study period. Trauma was defined as the cause in 65.2% (n=386) of the cases. 81.9% (n=316) of the cases were observed to have suffered blunt injury and 18.1% (n=70) penetrating injury. Death occurred at the scene of trauma in 56.7% (n=219) of the cases, in the pre-hospital period in 11.7% (n=45), and in hospital in 31.6% (n=122). In preventability analysis, it was decided that 4.1% (n=16) of the cases had the properties of being preventable, 14.5% (n=56) potentially preventable and 81.3% (n=314) non-preventable. Suboptimal care was determined in 65.3% (n=47) of the total cases, delayed intervention in 58.3% (n=42), error in the medical method decision in 8.3% (n=6), delayed or wrong diagnosis in 1.4% (n=1), and inappropriate or incorrect medical application in 1.4% (n=1).

Conclusion: High rates of preventable deaths in the pre-hospital period, in cases of penetrating injuries, and particularly in cases of chest trauma were evaluated as noteworthy findings. Integrated working of pre-hospital emergency healthcare services with trauma centres would enable the development of trauma care and reduce the rates of preventable deaths.