Table 10.

 Preventable deaths among acute medical care cases where notes were reviewed holistically across study epochs before (epoch 1) and after (epoch 3) phase two of Safer Patients Initiative (SPI2)

Epoch	No of deaths (cases reviewed)	Preventable deaths ≥50%*				Preventable deaths <50%†
		1st reviewer only	2nd reviewer only	Both reviewers		1st reviewer only	2nd reviewer only	Both reviewers
Control hospital
1	17 (126)	0	0	1		0	0	1
2	24 (126)	0	0	1		1	0	1
3‡	23 (114)	0	0	2		0	1	2
Total	64 (366)	0	0	4		1	1	4
SPI2 hospitals
1	9 (117)	0	0	0		0	0	0
2	11 (120)	0	0	1		0	0	1
3‡	7 (122)	0	0	0		0	0	0
Total	27 (359)	0	0	1		0	0	1

*Preventable deaths ≥50%: on balance of probabilities substandard practice led to death.

†Preventable deaths <50%: substandard practice could have led to death but probability that it did was <50%.

‡After intervention.