title: The implications of the patterns of error associated with acute trauma care in rural hospitals in South Africa for quality improvement programs and trauma education.
abstract: BACKGROUND
  This audit uses error theory to analyze inappropriate trauma referrals from rural district hospitals in South Africa. The objective of the study is to inform the design of quality improvement programs and trauma educational programs.
  
  
  METHODS
  At a weekly metropolitan morbidity and mortality meeting all trauma admissions to the Pietermaritzburg Metropolitan Trauma Service are reviewed. At the meeting problematic and inappropriate referrals and cases of error are identified. We used the (JCAHO) taxonomy to analyze these errors.
  
  
  RESULTS
  During the period July 2009-2011 we received 1512 trauma referrals from our rural hospitals. Of these referrals we judged 116 (13%) to be problematic. This group sustained a total of 142 errors. This equates to 1.2 errors per patient. There were 87 males and 29 females in this group. The mechanism of injury was as follows, blunt trauma (66), stabs (32), gunshot wounds (GSW) (13) and miscellaneous five. The types of error consisted of assessment errors (85), resuscitation errors (26), logistics errors (14) and combination errors (17). The cause of the errors was planning failure in 68% of cases and execution failure in the remaining 32% of cases. The assessment errors involved the abdomen (50), chest (9), vascular system (8) and miscellaneous (18). The resuscitation errors involved airway (4), chest (11), vascular access (8) and cervical spine immobilization (3).
  
  
  CONCLUSIONS
  Rural areas are error prone environments. Errors of execution revolve around the resuscitation process and current trauma courses specifically address these resuscitation deficits. However planning or assessment failure is the most common cause of error with blunt trauma being more prone to error of assessment than penetrating trauma.
authors.affiliation: Department of Surgery, Nelson R. Mandela School of Medicine, University of Kwa-Zulu Natal, South Africa. Electronic address: damianclar@gmail.com.
authors.forename: D L
authors.initials: DL
authors.lastname: Clarke
authors.forename: C
authors.initials: C
authors.lastname: Aldous
authors.forename: Sandie R
authors.initials: SR
authors.lastname: Thomson
mesh_terms: D003951:Diagnostic Errors / Q000401:mortality / Q000706:statistics & numerical data; D005260:Female; D006780:Hospitals, Rural / Q000458:organization & administration* / Q000592:standards*; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000009:adverse effects / Q000145:classification* / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D058996:Quality Improvement; D012151:Resuscitation / Q000592:standards; D013019:South Africa / Q000453:epidemiology; D014193:Trauma Centers / Q000592:standards; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality; D014949:Wounds, Nonpenetrating / Q000150:complications
keywords: Assessment failure; Error; Quality improvement programs; Resuscitation failure; Rural trauma care