An Objective Analysis of Process Errors in Trauma Resuscitations

Abstract

Abstract. Objective: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. Methods: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. Results: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2.4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5.1). The largest number of errors involved the failure to record, and perhaps observe, bedside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. Conclusions: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

Trauma Resuscitation Errors and Computer-Assisted Decision Support

“…1,2 Errors occur because of time pressure, inexperience, reliance on memory, multitasking, and failures in trauma team coordination, especially during the initial minutes of patient reception and resuscitation. [3][4][5][6] Human variables that confound a standardized environment and lead to avoidable errors have been addressed by the airline and other industries. For example, computerized prompts are built into flightcontrol systems, providing immediate feedback and error avoidance.…”

Profiles in Patient Safety: Confirmation Bias in Emergency Medicine

“…12 One study of trauma patients found that there were reasoning errors in 100% of trauma resuscitations. 13 The use of heuristics is a necessary evil in caring for ED patients. The use of heuristics is inevitable to allow clinicians to maintain efficiency and not chase the metaphorical zebras (a colloquial term designating those possible diagnoses that are least likely and most difficult to confirm on the basis of given clinical data, as in the saying, ''when you hear hoofbeats, think horses, not zebras'').…”

Resuscitation Team Organization for Emergency Departments: A Conceptual Review and Discussion

“…Team leaders often do not (or will not) follow basic protocols [47][48][49]. Medical errors tend to occur more frequently in stochastic environments or when team dynamics and communication are flawed [18,[50][51][52][53].…”