Potentially preventable deaths in the Victorian Audit of Surgical Mortality

BACKGROUND: The Victorian Audit of Surgical Mortality (VASM) seeks to peer-review all deaths associated with surgical care. This study aimed to examine the mortalities that were determined by the assessor to be potentially preventable, and identify the clinical factors associated with these cases. The assessment of preventability of death and its relationship to management issues at different stages of the admission episode, as opposed to whether the management issue(s) alone were preventable have not been reported previously. METHODS: Mortality data from the VASM audit since 2007 that completed the peer-review process were retrospectively analysed. Mortalities identified as being preventable were assessed to determine any treatment errors. RESULTS: A total of 6155 deaths were assessed. Of these, 14.6% (896/6155) were considered to be potentially preventable. Where a second-line assessment was requested (1113/6155, 17.5% cases), 48.3% of these deaths were considered potentially preventable. Elective patient deaths were more likely to be potentially preventable (P < 0.001), especially in public patients. Lack of timely involvement of senior staff, inappropriate treatment delay and failure of problem recognition were factors most frequently associated with potentially preventable mortality. CONCLUSION: Overall assessment of the preventability of death is unique to VASM. This allows an additional level of analysis to be applied to the circumstances surrounding each mortality and correlation of preventability of death with clinical management issues provides important feedback to surgeons and health-care providers to further improve the safety and quality of care.