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Table 4 Possible preventable events leading to death

From: Adverse events and in-hospital mortality: an analysis of all deaths in a Norwegian health trust during 2011

Age

Event(s) leading to death

85

Pneumonia, ultrasound guided biopsy. Not monitored. Next night developed signs of septic shock with hypotension, lactate 18 mmol/l and severe hypoxemia. Died. Death probably related to the biopsy.

90

Isoprenaline infusion with a syringe pump. The hosing lost connection with syringe, and before this was detected the patient development of therapy resistant bradycardia and death.

60

Admission with suspected endocarditis, not monitored. Had cardiac arrest on ward, resuscitation efforts negative. Died.

64

Elective surgery for liver metastasis. Perioperative lesion of the liver vein with profuse bleeding. Death on the operating table.

73

Admitted with tentative diagnosis: urethral stone, and was treated for this. Patient suddenly developed circulatory arrest and died. Post mortem autopsy revealed peritonitis and perforated colon. Error of omission.

80

Whiple’s operation performed. In recovery room delirious, and a new gastric tube had to be reinserted. This resulted in vomiting and pulmonary aspiration leading to cardiac arrest and death.

77

Urethral catheter inserted which resulted in profound urethral bleeding and hypovolemic shock. Next day severe sepsis secondary to urinary tract infection. Death.

57

Iatrogenic opiate overdose postoperatively. Found dead in bed. Probably related to opioid overdose.

68

Thoracic drain inserted to remove pleural effusion. After several hours development of circulatory shock and anemia. Died. Post mortem exam revealed large amount of blood in thoracic cage.

64

Postoperative pneumothorax during mechanical ventilation. Insertion of pleural drain resulted in bleeding from an intercostal artery, leading to thoracotomy because of ongoing bleeding. Had a cardiac arrest. ROSC, but severe cerebral injury led to withdrawal of treatment some days later.

80

Pleural drain inserted. Resulted in bleeding and cardiac arrest. Received anticoagulation drugs.

66

Cancer pulm. Operated. After surgery airway problems (ET tube) with hypoxemia and hypotension. Did not wake up, and treatment was stopped after 6 days.

60

Abdominal pain, given ketobemidon. Low body weight. Registered low respiratory rate during next night, nothing was done and patient found dead in the morning. Possible opioid overdose.

81

Because of delirum given klometiazol (Heminevrin) i.v. One hour later cardiac arrest and with no ROSC. Died.

89

17 days in hospital with abdominal pain, no diagnosis made. Patient died. Post mortem revealed gallstone and cholecystitis. Error of omission

86

Dyspnoe and AMI, given antithrombotic drugs that resulted in profound bleeding and haemorrhagic shock. Death.