Confidential enquiry into avoidable vehicle accident deaths in the province of Modena, Italy

The authors describe the methods and results of a kind of study - confident ial enquiries into avoidable deaths - very rarely performed in the Mediterr anean area. After assessing some quali/quantitative evaluation criteria, an independent expert panel investigated the quality of each step in emergenc y health care. Information was collected by clinical and forensic reports ( clinical method). Of 102 cases, 4 were avoidable deaths and 18 probably avo idable. These results, which are comparable with other similar ones found i n Italy (autoptic method) and abroad, have been useful in highlighting some health care errors: in particular, in on-site care and in emergency depart ment diagnosis and treatment. Other avoidable factors emerging were the ina ppropriateness of transporting severe trauma cases to a small hospital lack ing proper equipment and trained staff, and the importance of staff trainin g in first emergency care of severe trauma on ambulance. This situation had been highlighted previously and led to implementation of trauma centres. T he methods implemented turned out to be quite statistically reproducible an d have been used in local health care planning, especially in the rearrange ment of ambulance deployment and emergency staff training.