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 |