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Identifying and Addressing Preventable Process Errors in Trauma Care

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Abstract

Background

Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies.

Methods

Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors.

Results

A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission.

Conclusions

This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions.

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Author information

Author notes

  1. Philip H. Pucher

    Present address: Department of Surgery and Cancer, St Mary’s Hospital, 10th Floor QEQM, Praed Street, London, UK, W2 1NY

Authors and Affiliations

  1. Department of Surgery and Cancer, Imperial College, London, UK

    Philip H. Pucher, Rajesh Aggarwal & Ara Darzi

  2. Faculty of Medicine, Imperial College, London, UK

    Ahmed Twaij

  3. St Mary’s Hospital Major Trauma Center, Imperial College Healthcare NHS Trust, London, UK

    Nicola Batrick & Michael Jenkins

Authors
  1. Philip H. Pucher
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  2. Rajesh Aggarwal
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  3. Ahmed Twaij
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  4. Nicola Batrick
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  5. Michael Jenkins
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  6. Ara Darzi
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Corresponding author

Correspondence to Philip H. Pucher.

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Pucher, P.H., Aggarwal, R., Twaij, A. et al. Identifying and Addressing Preventable Process Errors in Trauma Care. World J Surg 37, 752–758 (2013). https://doi.org/10.1007/s00268-013-1917-9

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  • DOI: https://doi.org/10.1007/s00268-013-1917-9

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