Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems
- 17 Downloads
Critical incident reporting systems (CIRS) are considered to be a valid instrument to identify typical errors in various clinical settings as well as in prehospital emergency medicine. Our aim was to review incidents and errors in the care of trauma patients during the period of emergency trauma room treatment before their transfer to the intensive care unit or the operation room.
We screened six open access and German language-based CIRS-platforms on the internet.
We identified 78 critical incidents. They could be divided into four groups: organization related (n = 30), communication related (n = 6), equipment related (n = 28), and medical error (n = 23). Within the category, typical, common, or frequent clusters were identified, such as incomplete trauma team, malfunctioning equipment, or a lack of communication skills. In 12 cases (15.4%), patients were reported to have been harmed, mostly by medical errors. Three reported incidents (3.6%) were considered near-incidents.
Our results demonstrate that using CIRS is able to reveal individual or rare errors and allows for the identification of systematic errors and deficiencies in the acute care of trauma patients in the trauma room. This may guide quality control and quality improvement measures to be focused on the most common fields of demand.
KeywordsCIRS Trauma Polytrauma Critical incident
We thank Ms. Katherine Noelle Brooks (University of Seattle, 550 17th Ave, 98122 Seattle, WA, USA) for language revision.
Compliance with ethical standards
Conflict of interest
Matthias Niemeier, Uwe Hamsen, Emre Yilmaz, Thomas Armin Schildhauer and Christian Waydhas declare that they have no conflict of interest.
- 2.World Alliance for Patient Safety. WHO draft guidelines for adverse event reporting and learning systems. 2005. https://apps.who.int/iris/bitstream/handle/10665/69797/WHO-EIP-SPO-QPS-05.3-eng.pdf?sequence=1&isAllowed=y. Accessed 4 May 2018.
- 9.Major trauma: service delivery. NICE National Institute for Health and Care Excellence. 2016. https://www.nice.org.uk/guidance/NG40/chapter/Recommendations#organisation-of-hospital-major-trauma-services. Accessed 4 May 2018.
- 11.Rotondo MCC, Smith R. Resources for optimal care of the injured patient. Chicago: American College of Surgeons; 2014.Google Scholar
- 12.Quality Indicators for Trauma Outcome and Performance. The trauma audit & research network. 2010. https://www.tarn.ac.uk/content/downloads/27/Quality%20Indicators_26-02-10.pdf. Accessed 6 May 2018.
- 17.Deutsche Gesellschaft für Unfallchirurgie. Weißbuch Schwerverletzten-Versorgung. Stuttgart. 2012.Google Scholar