An objective analysis of process errors in trauma resuscitations

Area of Science:

• Medical Informatics
• Trauma Surgery
• Clinical Decision Support

Background:

• Trauma resuscitation protocols are critical for managing penetrating thoracoabdominal injuries.
• A computer-based system for applying these protocols was previously validated.
• Objective critique of clinical reasoning in trauma care is essential for quality improvement.

Purpose of the Study:

• To describe the application of a validated computer system for objectively critiquing trauma resuscitation care.
• To identify and classify process errors in clinical reasoning for patients with penetrating thoracoabdominal trauma.
• To evaluate reasoning errors independently of patient outcomes.

Main Methods:

• A chronological narrative of patient care was input into a computer program.
• Actual patient care was compared against validated computer protocols at decision points.
• Differences were classified as critical/noncritical errors of commission, omission, or procedure selection using a scoring system.

Main Results:

• Reasoning errors occurred in 100% of the 97 cases studied, averaging 11.9 per case.
• Errors of omission were more frequent (2.4/case) and severe (19.4/error) than errors of commission (1.2/case, 5.1/error).
• The most common error was the failure to record or consider relevant information (7.4 missing items/patient).

Conclusions:

• Process errors in clinical reasoning are ubiquitous in trauma resuscitation, present in every case.
• Errors of omission were more severe and prevalent than errors of commission.
• Failure to consider or document available relevant information was the most frequent reasoning error.