Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system.

J Trauma Acute Care Surg

From the Department of Surgery (D.M.H., M.P.G., P.W., A.B.N.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Department of Surgery (S.P.M.), UT Southwestern Medical Center, Dallas, Texas; Department of Surgery (R.M.S.), University of Texas Health Science Center, San Antonio, Texas; Trauma Quality Improvement Program (B.P., A.T., A.B.N.), American College of Surgeons, Chicago, Illinois; Feinberg School of Medicine (A.T.), Northwestern University, Chicago, Illinois; Department of Anesthesia (A.J.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; and Division of Trauma, Critical Care and Burn Surgery (E.M.B.), University of Washington, Seattle, Washington.

Published: March 2022

Background: Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the Mortality Reporting System.

Methods: An anonymous structured web-based reporting template based on the Joint Commission on Accreditation of Healthcare Organizations taxonomy was made available to trauma centers participating in the Trauma Quality Improvement Program to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions.

Results: Over a 2-year period, 395 deaths were reviewed. Of the mortalities, 33.7% were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%), and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers could not identify a specific strategy to prevent future harm.

Conclusion: Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm.

Level Of Evidence: Therapeutic/Care Management, level V.

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000003485DOI Listing

Publication Analysis

Top Keywords

mortality reporting
12
trauma centers
12
trauma
8
trauma care
8
reporting system
8
preventable deaths
8
trauma quality
8
quality improvement
8
improvement program
8
prevent future
8

Similar Publications

Objective: Splenectomy is regularly performed in total and distal pancreatectomy due to technical reasons, lymph node dissection and radicality of the operation. However, the spleen serves as an important organ for competent immune function, and its removal is associated with an increased incidence of cancer and a worse outcome in some cancer entities (Haematologica 99:392-398, 2014; Dis Colon Rectum 51:213-217, 2008; Dis Esophagus 21:334-339, 2008). The impact of splenectomy in pancreatic cancer is not fully resolved (J Am Coll Surg 188:516-521, 1999; J Surg Oncol 119:784-793, 2019).

View Article and Find Full Text PDF

Disparities Attributable to Sex Differences in 4680 Lumbar Fusion Outcomes.

World Neurosurg

December 2024

Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

Background: While studies have examined the relationship between sex and outcomes after lumbar fusion surgery, few have strictly controlled for other patient-level variables. In this study, we use coarsened exact matching to determine the effect of patient-reported sex on spinal fusion outcomes.

Methods: Outcomes across 4680 consecutive adult single-level, posterior-only lumbar fusions at a multihospital academic medical center were retrospectively assessed.

View Article and Find Full Text PDF

Robust multi-modal fusion architecture for medical data with knowledge distillation.

Comput Methods Programs Biomed

December 2024

School of Biomedical Engineering, Capital Medical University, No.10, Xitoutiao, You An Men, Fengtai District, Beijing 100069, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, No.10, Xitoutiao, You An Men, Fengtai District, Beijing 100069, China. Electronic address:

Background: The fusion of multi-modal data has been shown to significantly enhance the performance of deep learning models, particularly on medical data. However, missing modalities are common in medical data due to patient specificity, which poses a substantial challenge to the application of these models.

Objective: This study aimed to develop a novel and efficient multi-modal fusion framework for medical datasets that maintains consistent performance, even in the absence of one or more modalities.

View Article and Find Full Text PDF

Background And Objective: Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. Despite advances in treatment, metastatic colorectal cancer (mCRC) remains a significant challenge due to its heterogeneity and resistance to therapy. Regorafenib, a multikinase inhibitor, can inhibit tumor progression through multiple mechanisms, thereby improving patient prognosis.

View Article and Find Full Text PDF

Introduction: Thyroid storm or severe hyperthyroidism can present with various signs and symptoms. They are mostly controlled by general treatment, such as anti-thyroid drugs and other medications to control clinical features. However, in rare cases, they are more severe, and they only respond to more aggressive treatments, such as plasmapheresis and total thyroidectomy.

View Article and Find Full Text PDF

Want AI Summaries of new PubMed Abstracts delivered to your In-box?

Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!