• Shokei Matsumoto, Kyoungwon Jung, Alan Smith, and Raul Coimbra.
• Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego, 200 W. Arbor Drive, San Diego, CA, 92103-8896, USA.
• Surg. Today. 2018 Nov 1; 48 (11): 1004-1010.

PurposeTo establish the preventable and potentially preventable death rates in a mature trauma center and to identify the causes of death and highlight the lessons learned from these cases.MethodsWe analyzed data from a Level-1 Trauma Center Registry, collected over a 15-year period. Data on demographics, timing of death, and potential errors were collected. Deaths were judged as preventable (PD), potentially preventable (PPD), or non-preventable (NPD), following a strict external peer-review process.ResultsDuring the 15-year period, there were 874 deaths, 15 (1.7%) and 6 (0.7%) of which were considered PPDs and PDs, respectively. Patients in the PD and PPD groups were not sicker and had less severe head injury than those in the NPD group. The time-death distribution differed according to preventability. We identified 21 errors in the PD and PPD groups, but only 61 (7.3%) errors in the NPD group (n = 853). Errors in judgement accounted for the majority and for 90.5% of the PD and PPD group errors.ConclusionsAlthough the numbers of PDs and PPDs were low, denoting maturity of our trauma center, there are important lessons to be learned about how errors in judgment led to deaths that could have been prevented.

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