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Table 3 Opportunities for improvement in the preventable group of deaths as identified by peer-review

From: Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths

Opportunity for improvement n = 2057 Percentage
Resuscitation related:   
Delayed control of pelvic abdominal hemorrhage 51 2.5
Delayed control of intrathoracic hemorrhage 25 1.2
Delayed resuscitation 108 5.2
Inadequate resuscitation 152 7.4
Lack of blood 11 0.5
Protocol lack or lack of adherence:   
Intensive monitoring required 109 5.3
Unavailability of ventilator 39 0.1
Unstable patient sent to CT 9 0.8
Inappropriate ventilatory management 1 1.9
Delay in cervical spine 9 0.4
Left to die 49 2.4
Prehospital delay 212 10.3
Unknown cause 4 0.2
Lack of investigations 11 0.5
Lack of protocols 24 1.2
Lack of adherence to protocols 4 0.2
Head Injury and Airway related:   
Airway 293 14.3
Traumatic Brain injury 307 14.9
No CT uninvestigated 56 2.7
Untreated head injury 64 3.1
Untreated head injury-no surgery done 109 5.3
Surgery related:   
Inappropriate surgery done 5 0.2
Unduly long surgery done 61 3.0
Unstable patient operated on 5 0.2
Negative explorations 1 0.1
Injury prevention:   
Burns prevention 117 5.7
Long stay complications:   
DIC 1 0.1
Sepsis 39 1.9
Pneumonia 16 0.8
Old age related complications 19 0.9
Ventilator related complications 104 5.1
Miscellaneous issues:   
Could not be determined 26 1.2
Misclassified 5 0.2