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To determine the preventable death rate (PDR) and the frequency and types of inappropriate medical care in a large, rural region of Michigan. A prospective study of all deaths caused by injury during a 1-year period. Preventability of death and appropriateness of care were determined using a structured implicit review process and expert panel. A second panel was convened to confirm the reliability of the review process. One hundred fifty-five injury-related deaths underwent panel review. Four deaths (2.6%) were found to be definitely preventable and 16 (10.3%) possibly preventable, for a combined preventable death rate of 12.9%. Sixty-five deaths (41.9%) occurred in the emergency department or hospital; 18 of these (27.7%) were judged to be definitely preventable or possibly preventable. Forty-three episodes of inappropriate care were identified in 27 (17.4%) of the 155 cases reviewed. These occurred primarily in the emergency department and hospital rather than during prehospital care or transfer. A relatively small percentage of trauma fatalities in rural Michigan could have been prevented by more appropriate or timely medical care. Efforts to improve the care of injured persons in rural Michigan should be directed primarily at the emergency department and inpatient phases of trauma system care.