• G Kubalak, M Rhodes, D Boorse, and L F D'Amelio.
• Division of Trauma, Lehigh Valley Hospital Center, Allentown, Pennsylvania.
• J Trauma. 1991 Sep 1;31(9):1258-62; discussion 1262-4.

AbstractTo 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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