Unexpected death on the non-ICU trauma ward.

Publication/Presentation Date

9-1-1991

Abstract

To 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.

Volume

31

Issue

9

First Page

1258

Last Page

1262

ISSN

0022-5282

Disciplines

Medicine and Health Sciences

PubMedID

1920557

Department(s)

Patient Care Services / Nursing, Department of Emergency Medicine

Document Type

Article

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