• Injury · Sep 1991

    Preventable deaths after head injury: a clinical audit of performance.

    • I C Phair, D J Barton, M J Allen, and M R Barnes.
    • Accident and Emergency Department, Leicester Royal Infirmary, UK.
    • Injury. 1991 Sep 1;22(5):353-6.

    AbstractA retrospective trauma audit of 267 consecutive patients presenting to the resuscitation room of an accident and emergency department identified 107 (M = 0.73) patients with CNS predominant injuries in a period of 1 year. The mortality rate was 33 per cent. Application of the TRISS method indicated that 18 (51 per cent) of the 35 deaths (Z = 5.74, P less than 0.001) were mathematically unexpected; no unexpected survivors were identified. Subsequent peer review agreed that death was preventable in 11 cases. The peer panel suggested that the lack of an on-site neurosurgical service may have affected the outcome of this group of patients adversely.

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