1. Paper reading Int. 林泰祺

2. 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 Hugh M. Foy, MD Ronald V. Maier, MD Ann Surg 244(3):371-380, 2006. © 2006 Lippincott Williams & Wilkins 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 Hugh M. Foy, MD Ronald V. Maier, MD Ann Surg 244(3):371-380, 2006. © 2006 Lippincott Williams & Wilkins

3. Introduction Trauma care creates a perfect storm for medical errors: –unstable patients –incomplete histories –time-critical decisions –concurrent tasks –involvement of many disciplines –junior personnel working after-hours in busy emergency departments Trauma care creates a perfect storm for medical errors: –unstable patients –incomplete histories –time-critical decisions –concurrent tasks –involvement of many disciplines –junior personnel working after-hours in busy emergency departments

4. Introduction Trauma given –high baseline mortality rates –often complicated in-hospital care –relative paucity of widely applicable management protocols, especially beyond the Golden Hour of initial resuscitation, to which Advanced Trauma Life Support (ATLS) protocols apply Trauma given –high baseline mortality rates –often complicated in-hospital care –relative paucity of widely applicable management protocols, especially beyond the Golden Hour of initial resuscitation, to which Advanced Trauma Life Support (ATLS) protocols apply

5. Introduction In this study, we aimed to identify errors that had contributed to the death of trauma patients at a specific high-volume regional trauma center over a 9-year period and determine any apparent patterns of occurrence We also aimed to examine the effect of introduction of local institutional policies on reducing error In this study, we aimed to identify errors that had contributed to the death of trauma patients at a specific high-volume regional trauma center over a 9-year period and determine any apparent patterns of occurrence We also aimed to examine the effect of introduction of local institutional policies on reducing error

6. Method All trauma deaths that occurred after arrival in the emergency room and prior to discharge from Harborview Medical Center (HMC) in the 9 years from January 1, 1996 to December 31, 2004 were eligible for this study Those deaths identified at –M&M meetings as being possibly –Self-reporting of errors –Chart review All trauma deaths that occurred after arrival in the emergency room and prior to discharge from Harborview Medical Center (HMC) in the 9 years from January 1, 1996 to December 31, 2004 were eligible for this study Those deaths identified at –M&M meetings as being possibly –Self-reporting of errors –Chart review

7. Method Appraised all deaths that had less than 50% probability of death at the time of admission, as determined by the Trauma Injury Severity Score (TRISS) or the Harborview Adjusted Risk of Mortality (HARM) score Potential errors were identified by –examining the cause of death and its antecedent events –reviewing the process of care for apparent errors in decision-making, timing, conduct of procedures, and nonprocedural mishaps Appraised all deaths that had less than 50% probability of death at the time of admission, as determined by the Trauma Injury Severity Score (TRISS) or the Harborview Adjusted Risk of Mortality (HARM) score Potential errors were identified by –examining the cause of death and its antecedent events –reviewing the process of care for apparent errors in decision-making, timing, conduct of procedures, and nonprocedural mishaps

8. Method Each case of suspected error was subjected to peer review at one or more of the following forums: –weekly M&M meetings –monthly trauma council QA meetings –quarterly hospital quality assurance forums –annual regional QA forums Each case of suspected error was subjected to peer review at one or more of the following forums: –weekly M&M meetings –monthly trauma council QA meetings –quarterly hospital quality assurance forums –annual regional QA forums

9. Error Definition and Classification Error Impact, which in our study was death Error Type, as errors in diagnosis, treatment, prevention, or other (equipment failures; communication failures; and errors in transfer) Error Impact, which in our study was death Error Type, as errors in diagnosis, treatment, prevention, or other (equipment failures; communication failures; and errors in transfer)

10. Error Definition and Classification Error Domain, –initial assessment and resuscitation (including prehospital); –secondary survey and tests (eg, CT); interhospital transfers –initial interventions (eg, OR, Angio); ICU; general ward; and rehabilitation Error Domain, –initial assessment and resuscitation (including prehospital); –secondary survey and tests (eg, CT); interhospital transfers –initial interventions (eg, OR, Angio); ICU; general ward; and rehabilitation

11. Error Definition and Classification Error Cause, which refers to the psychologic cause, that is –Input error: the input data are incorrectly perceived; therefore, an incorrect intention is formed and the wrong action is performed –Intention error: the input data are correctly perceived, but an incorrect intention is formed, and the wrong action is performed –Execution error: the input data are correctly perceived and the correct intention is formed, but the wrong action is performed Error Cause, which refers to the psychologic cause, that is –Input error: the input data are incorrectly perceived; therefore, an incorrect intention is formed and the wrong action is performed –Intention error: the input data are correctly perceived, but an incorrect intention is formed, and the wrong action is performed –Execution error: the input data are correctly perceived and the correct intention is formed, but the wrong action is performed

12. Pattern Recognition and Impact of Policies The occurrence of errors relative to each policy's implementation was then plotted to give an indication of whether or not such policies had been effective in reducing error occurrence Observations were categorized into whether or not a new policy was implemented during the study period The occurrence of errors relative to each policy's implementation was then plotted to give an indication of whether or not such policies had been effective in reducing error occurrence Observations were categorized into whether or not a new policy was implemented during the study period

13. Results In 9 years between 1996 and 2004, inclusive, there were 44,401 trauma patient admissions that resulted in 2594 deaths (5.8% of admissions) Of the deaths: –69% were male –median age was 46 years –74% were due to blunt trauma –17% due to penetrating trauma –9% due to burns and other mechanisms In 9 years between 1996 and 2004, inclusive, there were 44,401 trauma patient admissions that resulted in 2594 deaths (5.8% of admissions) Of the deaths: –69% were male –median age was 46 years –74% were due to blunt trauma –17% due to penetrating trauma –9% due to burns and other mechanisms

14. Results 53 deaths (2.0%) had quality of care concerns discussed at M&M review that may have contributed to the death 601 deaths (1.4% admissions, 23.2% deaths) had less than 50% mortality risk at the time of admission, as defined by TRISS and HARM scores After this review, 64 patients (0.14% admissions, 2.5% deaths over the 9- year period) had recognized errors in care that were likely to have contributed to their death gogo 53 deaths (2.0%) had quality of care concerns discussed at M&M review that may have contributed to the death 601 deaths (1.4% admissions, 23.2% deaths) had less than 50% mortality risk at the time of admission, as defined by TRISS and HARM scores After this review, 64 patients (0.14% admissions, 2.5% deaths over the 9- year period) had recognized errors in care that were likely to have contributed to their death gogo

15. Results The major clinical groupings of errors included: –hemorrhage control (28%) –airway management (16%) –inappropriate management of unstable patients (14%) –complications of procedures (12%) –inadequate prophylaxis (11%) –missed or delayed diagnoses (11%) –over-resuscitation with fluids (5%) –other poor management decisions (3%) gogo The major clinical groupings of errors included: –hemorrhage control (28%) –airway management (16%) –inappropriate management of unstable patients (14%) –complications of procedures (12%) –inadequate prophylaxis (11%) –missed or delayed diagnoses (11%) –over-resuscitation with fluids (5%) –other poor management decisions (3%) gogo

16. Results By phase of trauma management: –34% of errors occurred in the ED (20% during initial assessment and resuscitation, 14% during the secondary survey and initial diagnostic tests) –8% during stabilization and interhospital transport –11% during initial interventions (surgery and/or angiography) –37% during the intensive care unit stay –9% during the general or rehabilitation ward inpatient stay By phase of trauma management: –34% of errors occurred in the ED (20% during initial assessment and resuscitation, 14% during the secondary survey and initial diagnostic tests) –8% during stabilization and interhospital transport –11% during initial interventions (surgery and/or angiography) –37% during the intensive care unit stay –9% during the general or rehabilitation ward inpatient stay

17. Results By type of error: –61% were errors of treatment –20% were errors of prophylaxis –13% were errors of diagnosis –5% were errors associated with transfer –only 1 was a result of equipment failure By type of error: –61% were errors of treatment –20% were errors of prophylaxis –13% were errors of diagnosis –5% were errors associated with transfer –only 1 was a result of equipment failure

18. Results By the internal processing classification of cause: –23% were input errors –50% were intention errors –27% were execution gogo By the internal processing classification of cause: –23% were input errors –50% were intention errors –27% were execution gogo

19. Discussion This study addressed the types and nature of errors that contribute to trauma deaths and the integration of error detection into an institutional patient safety program Among 44,401 admissions and 2594 deaths over 9 years, 2.47% of deaths at our institution were contributed to by errors 2% to 3% error-related death rate may be an absolute baseline in complex trauma systems This study addressed the types and nature of errors that contribute to trauma deaths and the integration of error detection into an institutional patient safety program Among 44,401 admissions and 2594 deaths over 9 years, 2.47% of deaths at our institution were contributed to by errors 2% to 3% error-related death rate may be an absolute baseline in complex trauma systems

20. Discussion This study is likely to assist error reduction in 3 important ways: –Through identification of specific categories of errors –Through considering the type and underlying psychologic cause –Demonstrating the likely effectiveness of such evidence- based institutional protocols gogo This study is likely to assist error reduction in 3 important ways: –Through identification of specific categories of errors –Through considering the type and underlying psychologic cause –Demonstrating the likely effectiveness of such evidence- based institutional protocols gogo

21. Discussion This study combines contemporary understanding of error causation, classification, and remediation with an institution specific process The process uses existing systems and is goal-oriented in seeking out patterns of errors, which can then be targeted The process is likely to be relevant to other institutions and may be as applicable in other surgical disciplines as it is in trauma This study combines contemporary understanding of error causation, classification, and remediation with an institution specific process The process uses existing systems and is goal-oriented in seeking out patterns of errors, which can then be targeted The process is likely to be relevant to other institutions and may be as applicable in other surgical disciplines as it is in trauma

22. Thank you