title: Opportunities for improvement in the management of patients who die from haemorrhage after trauma.
abstract: BACKGROUND
  Bleeding is the leading cause of preventable death after injury. This retrospective study aimed to characterize opportunities for performance improvement (OPIs) identified in patients who died from bleeding and were considered by the quality improvement system of a major trauma centre.
  
  
  METHODS
  All trauma deaths in 2006-2010 were discussed at the trauma morbidity and mortality meeting. Deaths from haemorrhage were identified and subjected to qualitative and quantitative evaluation. OPIs were identified and remedial action was taken.
  
  
  RESULTS
  During the study interval there were 7511 trauma team activations; 423 patients died. Haemorrhage was the second most common cause of death, in 112 patients, and made a substantial contribution to death in a further 15. For 84 of these 127 patients, a total of 150 OPIs were identified. Most arose in the emergency department, but involved personnel from many departments. Problems with decision-making were more common than errors in technical skill. OPIs frequently involved the decision between surgery, radiology and further investigation. Delayed and inappropriate surgery occurred even when investigation and diagnosis were appropriate. The mortality rate among patients presenting in shock fell significantly over the study interval (P < 0·026).
  
  
  CONCLUSIONS
  Problems with judgement are more common than those of skill. Death from traumatic haemorrhage is associated with identifiable, remediable failures in care. The implementation of a systematic trauma quality improvement system was associated with a fall in the mortality rate among patients presenting in shock.
authors.affiliation: Trauma Clinical Academic Unit, Barts Health NHS Trust, London, UK. djoreilly@doctors.org.uk
authors.forename: D
authors.initials: D
authors.lastname: O'Reilly
authors.forename: K
authors.initials: K
authors.lastname: Mahendran
authors.forename: A
authors.initials: A
authors.lastname: West
authors.forename: P
authors.initials: P
authors.lastname: Shirley
authors.forename: M
authors.initials: M
authors.lastname: Walsh
authors.forename: N
authors.initials: N
authors.lastname: Tai
mesh_terms: D000328:Adult; D002423:Cause of Death; D002983:Clinical Competence / Q000592:standards; D004635:Emergency Medicine / Q000592:standards; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000517:prevention & control*; D006801:Humans; D015601:Injury Severity Score; D007600:Judgment; D008131:London / Q000453:epidemiology; D008297:Male; D058996:Quality Improvement / Q000458:organization & administration; D011787:Quality of Health Care; D012189:Retrospective Studies; D014193:Trauma Centers / Q000592:standards / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000401:mortality*