Patient safety in trauma: maximal impact management errors at a level I trauma center.
BACKGROUND
The Division of Research at JCAHO developed a taxonomy (common terminology and classification schema) to promote consistency in reporting and facilitate root cause analysis. We undertook a review of trauma management errors at our institution with maximal impact (death). The analysis was based on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) taxonomy.


METHODS
Trauma deaths between 2001 and 2006 at our Level I trauma were peer-reviewed to identify errors in management. The errors are classified according to type, domain, and cause.


RESULTS
Seventy-six (9.9%) of 764 deaths had management errors contributing to potentially preventable deaths in 60 (errors in management might have contributed to death) and preventable deaths (management errors definitely contributed to death) in 16 patients. Questionable resuscitation was the commonest type and involved poor treatment in the majority. Errors were made in all domains but most commonly in the emergency department and the operating room and in the resuscitative phase. Human errors predominated.


CONCLUSIONS
Management errors in the basics of trauma care continue even in established trauma centers, despite guidelines, protocols, and continuous performance improvement. Standardized reporting such as the taxonomy may result in progressive collection of patient safety data and lead to innovations to minimize these errors.
Ivatury
Rao R
RR
Division of Trauma, Critical Care & Emergency Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA. rivatury@hsc.vcu.edu
Guilford
Kelly
K
Malhotra
Ajai K
AK
Duane
Therese
T
Aboutanos
Michel
M
Martin
Nancy
N
D000328:Adult; D001344:Autopsy; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D014193:Trauma Centers; D014481:United States; D014768:Virginia; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*