Patterns of Errors Contributing to Trauma Mortality: Lessons Learned from 2594 Deaths
Russell L. Gruen, MD PhD*, Gregory J. Jurkovich, MD, Lisa K. McIntyre, MD*, Ronald V. Maier, MD, Hugh M. Foy, MD*
Harborview Medical Center, University of Washington, Seattle, WA, Harborview Medical Center, University of Washginton, Seattle, WA, Harborview Medical Center, University of Washington, Seattle, WA, Harborview Medical Center, University of Washington, Seattle, WA, Harborview Medical Center, University of Washington, Seattle, WA
OBJECTIVE: This study aimed to identify patterns of errors contributing to inpatient trauma deaths.
METHODS: All inpatient trauma deaths at a mature high-volume Level 1 regional trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital and annual regional forums. Patterns of errors were sought from the compiled longitudinal data.
RESULTS: In nine years there were 44,401 trauma patient admissions and 2594 deaths, of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: unsuccessful endotracheal intubations and delayed surgical airways (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (11%), delayed intervention for ongoing intrathoracic hemorrhage (11%), inadequate DVT or gastrointestinal prophylaxis (11%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths.
CONCLUSIONS: Preventable deaths will occur even in mature trauma systems. This review has identified error patterns for which policy interventions can be effectively targeted.
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