Clinical Science
Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology

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Abstract

Background

Benchmarking and classification of avoidable errors in trauma care are difficult as most reports classify errors using variable locally derived schemes. We sought to classify errors in a large trauma population using standardized Joint Commission taxonomy.

Methods

All preventable/potentially preventable deaths identified at an urban, level-1 trauma center (January 2002 to December 2010) were abstracted from the trauma registry. Errors deemed avoidable were classified within the 5-node (impact, type, domain, cause, and prevention) Joint Commission taxonomy.

Results

Of the 377 deaths in 11,100 trauma contacts, 106 (7.7%) were preventable/potentially preventable deaths related to 142 avoidable errors. Most common error types were in clinical performance (inaccurate diagnosis). Error domain involved primarily the emergency department (therapeutic interventions), caused mostly by knowledge deficits. Communication improvement was the most common mitigation strategy.

Conclusion

Standardized classification of errors in preventable trauma deaths most often involve clinical performance in the early phases of care and can be mitigated with universal strategies.

Section snippets

Study setting

The Trauma Center at Penn is a level-I trauma center accredited by the Pennsylvania Trauma Systems Foundation (PTSF), the sole accrediting authority of trauma centers in the state of Pennsylvania. The Trauma Center at Penn is based at the Hospital of the University of Pennsylvania (HUP), an academic tertiary care medical center in Philadelphia, Pennsylvania. The trauma service evaluates all patients meeting field triage criteria for trauma as established by the state bureau of Emergency Medical

Patient population and demographics

Annual trauma visits in the study time period ranged from 2,253 to 3,162 with a mean of 2,708 trauma contacts per year. A total of 11,100 trauma patient admissions were identified in the registry in the specified time period, of which 1,377 (12.4%) in-hospital deaths were reported. Of these, 18 (1.3% of all deaths, .16% of all trauma admissions) were classified as preventable, 88 (6.4% of all deaths, .79% of all trauma admissions) as potentially preventable, and 1,271 (92.3% of all deaths,

Comments

Depending on definitions used in published reports, the incidence of preventable death in trauma ranges from 2% to 29%.4, 15, 23, 24 Determining preventability of death depends on the identification of avoidable errors in the management of injured patients during their hospital care and sometimes also their prehospital care. In a 9-year review, we found a 7% incidence of preventable and potentially preventable deaths in our urban academic trauma center. We classified 142 avoidable errors

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