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

Area of Science:

• Patient Safety
• Trauma Care
• Healthcare Quality Improvement

Background:

• System-level solutions are crucial for patient safety, as highlighted by the 'To Err Is Human' report.
• Despite this, preventable deaths in trauma care remain a significant issue.
• The American College of Surgeons Trauma Quality Improvement Program (TQIP) established a Mortality Reporting System to analyze preventable trauma deaths.

Purpose of the Study:

• To identify factors contributing to potentially preventable deaths after injury.
• To evaluate the effectiveness of strategies implemented by trauma centers to mitigate future harm.

Main Methods:

• Utilized an anonymous, web-based reporting template for potentially preventable deaths in TQIP participating centers.
• Analyzed contributing factors to death and assessed the effectiveness of mitigation strategies.
• Categorized strategies by effectiveness, from person-focused to system-oriented interventions.

Main Results:

• Reviewed 395 deaths over 2 years; 33.7% were unanticipated.
• Errors involved management (50.9%), clinical performance (54.7%), and communication (56.2%), with human failure cited in 61%.
• Person-focused strategies (e.g., education) were common (56.0%), but effective system-based strategies were rarely used.

Conclusions:

• Current trauma care error reduction strategies often target provider performance over system-level interventions like automation or standardization.
• Trauma centers require enhanced support to develop and implement more robust, system-based mitigation strategies.
• Effective system-oriented interventions are underutilized in preventing recurrent errors and patient harm.