Patterns of Errors Contributing to Trauma Mortality: Lessons Learned From 2594 Deaths

摘要: Trauma care creates a “perfect storm” for medical errors: unstable patients, incomplete histories, time-critical decisions, concurrent tasks, involvement of many disciplines, and often junior personnel working after-hours in busy emergency departments. Studies several countries have identified adverse events, including death, that occur trauma care.1–4 In 1955, Robert M. Zollinger wrote the Archives Surgery about “preventability” deaths following motor vehicle crashes.5 In Journal American Medical Association, 30 years later, Donald Trunkey reviewed 29 studies preventable deaths,6 more been published since.7–11 These supported development regionalized care. They also provided insights into nature deaths, significance failure to evaluate abdomen, delays treatment, critical errors. However, estimates death rates were wide Trunkey's review, ranging from 2% 50%, indicating variability need standardized approaches its analysis minimized potential due definitions, methods used detect type reviewers making final determination.12,13 These showed surgeons pioneers error reduction quality improvement long before interest errors patient safety became widespread. More recently, much interdisciplinary expertise brought standardizing detection classification,14–16 understanding predisposing structural systemic factors17 defective information processing18,19 associated with error, effective mitigating strategies.20,21 In trauma, as all fields, it is likely recognizable clinical situations create predictable vulnerability human erroneous decision-making occurs response these can be forecast some degree.22 To reduce errors, institutions means identifying error-associated deaths. This difficult given high baseline mortality rates, complicated in-hospital care, relative paucity widely applicable management protocols, especially beyond “Golden Hour” initial resuscitation, which Advanced Life Support (ATLS) protocols apply. Furthermore, result may relatively infrequent; therefore, opportunities learn them limited by infrequent attention lack “institutional memory.” this study, we aimed identify had contributed patients at specific high-volume regional center over 9-year period determine any apparent patterns occurrence. We examine effect introduction local institutional policies on reducing incidence.