Unexpected ward deaths: preventable?
نویسندگان
چکیده
Methods In our center, deaths are systematically reported to the « Quality & Patient Safety Department » via a questionnaire inquiring into the causes, circumstances and characteristics of death. Medical records of «unexpected » deaths (UD) (= “death that was not expected to occur at that time or/and under these circumstances”) were reviewed, after exclusion of patients with DNR orders. We analyzed the characteristics of this group, focusing on signs of clinical deterioration (written notes) within 48h before death (vital signs (VS): s. blood pressure < 90mmHg; heart rate: < 50 >130 BPM; SaO2 < 90%; polypnea), or on presence (1 or more) of the following presumed risk factors (PRF): confusion contention unable to call inability to clear respiratory secretions independently. A comparison with non-unexpected deaths (NUD) has been made for systematically reported data (nursing and/or relatives presence; complications).
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