title: Identifying and addressing preventable process errors in trauma care.
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.
authors: Department of Surgery and Cancer, Imperial College, London, UK. p.pucher@imperial.ac.uk
authors: Philip H
authors: PH
authors: Pucher
authors: Rajesh
authors: R
authors: Aggarwal
authors: Ahmed
authors: A
authors: Twaij
authors: Nicola
authors: N
authors: Batrick
authors: Michael
authors: M
authors: Jenkins
authors: Ara
authors: A
authors: Darzi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006785:Hospitals, University / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008131:London; D008297:Male; D019300:Medical Errors / Q000009:adverse effects / Q000145:classification / Q000517:prevention & control / Q000706:statistics & numerical data*; D008875:Middle Aged; D017064:Process Assessment, Health Care; D012189:Retrospective Studies; D016037:Single-Blind Method; D062606:Tertiary Care Centers / Q000592:standards / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000592:standards / Q000706:statistics & numerical data*; D055815:Young Adult