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Table 2 Preventable unexpected death

From: Unexpected death within 72 hours of emergency department visit: were those deaths preventable?

Patient Age Main medical errors Provider ED diagnosis Cause of death
1 87 Denial of ICU admission ICU physician Sigmoid volvulus Sigmoid volvulus
2 79 wrong dose of opioids analgesic Orthopedist surgeon Urinary retention Opioid intoxication
3 81 No timely treatment of acute coronary syndrome Emergency physician Myocardial infarction Myocardial infarction
4 79 Pacemaker has not been monitored after a syncope Emergency physician Syncope Cardiac arrest
5 83 No fluid resuscitation no antibiotics Emergency physician Fatigue Severe sepsis
6 80 No treatment of congestive heart failure and no blood transfusion Emergency physician and orthopedic surgeon Hip fracture Congestive heart failure
7 87 No control of hyperkaliemia Emergency physician Metabolic acidosis Cardiac arrest
8 83 Undertriage on arrival Triage nurse Intracranial hemorrhage Intracranial hemorrhage
9 43 No chest X-ray before chest drainage Emergency physician Respiratory failure Hemothorax
10 77 No fluid resuscitation and wrong antibiotic administration Emergency physician Severe sepsis Severe sepsis
11 53 No fluid resuscitation and delay in antibiotic administration Emergency physician Urinary tract infection Severe sepsis
12 63 No reheating Emergency physician Hypothermia Hypothermia
13 71 No head CT performed Emergency physician Seizure Intracranial hemorrhage
14 85 No fluid resuscitation no antibiotics Emergency physician Severe sepsis Severe sepsis
15 61 Delay in performing ECG and treatment of acute coronary syndrome Emergency physician Acute coronary syndrome Acute coronary syndrome
16 74 No monitoring and no correction of hypokaliemia Emergency physician Ketoacidosis Hypokaliemia
17 70 No fluid resuscitation Emergency physician Pneumoniae Severe sepsis
18 54 No fluid resuscitation Emergency physician Sepsis Severe sepsis
19 85 No diagnosis and treatment of acute heart failure Orthopedist surgeon Hip fracture Heart failure
20 63 Insufficient fluid resuscitation and denial of ICU admission Emergency physician and ICU physician Upper GI bleed Upper GI bleed
21 87 No fluid resuscitation no antibiotics Emergency physician Arthritis Severe sepsis
22 77 No fluid resuscitation no antibiotics Emergency physician COPD exacerbation Severe sepsis
23 78 No fluid resuscitation and delay in antibiotic administration Emergency physician Severe sepsis Severe sepsis
24 57 Undertriage on arrival and denial of ICU admission Emergency physician and triage nurse Heart failure Heart failure
  1. ED, emergency department; ICU, intensive care unit; CT, computed tomography; ECG, electrocardiography; GI, gastrointestinal; COPD, chronic obstructive pulmonary disease.