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

TLDR: This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted, and has demonstrably reduced the incidence of associated error-related deaths.

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