Identifying and Addressing Preventable Process Errors in Trauma Care
Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error...
Ausführliche Beschreibung
Gespeichert in:
| Autor*in: |
Pucher, Philip H. [verfasserIn] |
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| Format: |
E-Artikel |
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| Sprache: |
Englisch |
| Erschienen: |
2013 |
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| Schlagwörter: |
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| Anmerkung: |
© Société Internationale de Chirurgie 2013 |
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| Übergeordnetes Werk: |
Enthalten in: World Journal of Surgery - Springer-Verlag, 1996, 37(2013), 4 vom: 24. Jan., Seite 752-758 |
|---|---|
| Übergeordnetes Werk: |
volume:37 ; year:2013 ; number:4 ; day:24 ; month:01 ; pages:752-758 |
| Links: |
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| DOI / URN: |
10.1007/s00268-013-1917-9 |
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SPR003442098 |
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| 520 | |a Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. | ||
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| 700 | 1 | |a Darzi, Ara |4 aut | |
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10.1007/s00268-013-1917-9 doi (DE-627)SPR003442098 (SPR)s00268-013-1917-9-e DE-627 ger DE-627 rakwb eng Pucher, Philip H. verfasserin aut Identifying and Addressing Preventable Process Errors in Trauma Care 2013 Text txt rdacontent Computermedien c rdamedia Online-Ressource cr rdacarrier © Société Internationale de Chirurgie 2013 Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. Trauma Center (dpeaa)DE-He213 Omission Error (dpeaa)DE-He213 Advance Trauma Life Support (dpeaa)DE-He213 Preventable Error (dpeaa)DE-He213 Surgical Safety Checklist (dpeaa)DE-He213 Aggarwal, Rajesh aut Twaij, Ahmed aut Batrick, Nicola aut Jenkins, Michael aut Darzi, Ara aut Enthalten in World Journal of Surgery Springer-Verlag, 1996 37(2013), 4 vom: 24. Jan., Seite 752-758 (DE-627)SPR003391159 nnns volume:37 year:2013 number:4 day:24 month:01 pages:752-758 https://dx.doi.org/10.1007/s00268-013-1917-9 lizenzpflichtig Volltext GBV_USEFLAG_A SYSFLAG_A GBV_SPRINGER AR 37 2013 4 24 01 752-758 |
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10.1007/s00268-013-1917-9 doi (DE-627)SPR003442098 (SPR)s00268-013-1917-9-e DE-627 ger DE-627 rakwb eng Pucher, Philip H. verfasserin aut Identifying and Addressing Preventable Process Errors in Trauma Care 2013 Text txt rdacontent Computermedien c rdamedia Online-Ressource cr rdacarrier © Société Internationale de Chirurgie 2013 Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. Trauma Center (dpeaa)DE-He213 Omission Error (dpeaa)DE-He213 Advance Trauma Life Support (dpeaa)DE-He213 Preventable Error (dpeaa)DE-He213 Surgical Safety Checklist (dpeaa)DE-He213 Aggarwal, Rajesh aut Twaij, Ahmed aut Batrick, Nicola aut Jenkins, Michael aut Darzi, Ara aut Enthalten in World Journal of Surgery Springer-Verlag, 1996 37(2013), 4 vom: 24. Jan., Seite 752-758 (DE-627)SPR003391159 nnns volume:37 year:2013 number:4 day:24 month:01 pages:752-758 https://dx.doi.org/10.1007/s00268-013-1917-9 lizenzpflichtig Volltext GBV_USEFLAG_A SYSFLAG_A GBV_SPRINGER AR 37 2013 4 24 01 752-758 |
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10.1007/s00268-013-1917-9 doi (DE-627)SPR003442098 (SPR)s00268-013-1917-9-e DE-627 ger DE-627 rakwb eng Pucher, Philip H. verfasserin aut Identifying and Addressing Preventable Process Errors in Trauma Care 2013 Text txt rdacontent Computermedien c rdamedia Online-Ressource cr rdacarrier © Société Internationale de Chirurgie 2013 Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. Trauma Center (dpeaa)DE-He213 Omission Error (dpeaa)DE-He213 Advance Trauma Life Support (dpeaa)DE-He213 Preventable Error (dpeaa)DE-He213 Surgical Safety Checklist (dpeaa)DE-He213 Aggarwal, Rajesh aut Twaij, Ahmed aut Batrick, Nicola aut Jenkins, Michael aut Darzi, Ara aut Enthalten in World Journal of Surgery Springer-Verlag, 1996 37(2013), 4 vom: 24. Jan., Seite 752-758 (DE-627)SPR003391159 nnns volume:37 year:2013 number:4 day:24 month:01 pages:752-758 https://dx.doi.org/10.1007/s00268-013-1917-9 lizenzpflichtig Volltext GBV_USEFLAG_A SYSFLAG_A GBV_SPRINGER AR 37 2013 4 24 01 752-758 |
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10.1007/s00268-013-1917-9 doi (DE-627)SPR003442098 (SPR)s00268-013-1917-9-e DE-627 ger DE-627 rakwb eng Pucher, Philip H. verfasserin aut Identifying and Addressing Preventable Process Errors in Trauma Care 2013 Text txt rdacontent Computermedien c rdamedia Online-Ressource cr rdacarrier © Société Internationale de Chirurgie 2013 Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. Trauma Center (dpeaa)DE-He213 Omission Error (dpeaa)DE-He213 Advance Trauma Life Support (dpeaa)DE-He213 Preventable Error (dpeaa)DE-He213 Surgical Safety Checklist (dpeaa)DE-He213 Aggarwal, Rajesh aut Twaij, Ahmed aut Batrick, Nicola aut Jenkins, Michael aut Darzi, Ara aut Enthalten in World Journal of Surgery Springer-Verlag, 1996 37(2013), 4 vom: 24. Jan., Seite 752-758 (DE-627)SPR003391159 nnns volume:37 year:2013 number:4 day:24 month:01 pages:752-758 https://dx.doi.org/10.1007/s00268-013-1917-9 lizenzpflichtig Volltext GBV_USEFLAG_A SYSFLAG_A GBV_SPRINGER AR 37 2013 4 24 01 752-758 |
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10.1007/s00268-013-1917-9 doi (DE-627)SPR003442098 (SPR)s00268-013-1917-9-e DE-627 ger DE-627 rakwb eng Pucher, Philip H. verfasserin aut Identifying and Addressing Preventable Process Errors in Trauma Care 2013 Text txt rdacontent Computermedien c rdamedia Online-Ressource cr rdacarrier © Société Internationale de Chirurgie 2013 Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. Trauma Center (dpeaa)DE-He213 Omission Error (dpeaa)DE-He213 Advance Trauma Life Support (dpeaa)DE-He213 Preventable Error (dpeaa)DE-He213 Surgical Safety Checklist (dpeaa)DE-He213 Aggarwal, Rajesh aut Twaij, Ahmed aut Batrick, Nicola aut Jenkins, Michael aut Darzi, Ara aut Enthalten in World Journal of Surgery Springer-Verlag, 1996 37(2013), 4 vom: 24. Jan., Seite 752-758 (DE-627)SPR003391159 nnns volume:37 year:2013 number:4 day:24 month:01 pages:752-758 https://dx.doi.org/10.1007/s00268-013-1917-9 lizenzpflichtig Volltext GBV_USEFLAG_A SYSFLAG_A GBV_SPRINGER AR 37 2013 4 24 01 752-758 |
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Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. 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Identifying and Addressing Preventable Process Errors in Trauma Care |
| abstract |
Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. © Société Internationale de Chirurgie 2013 |
| abstractGer |
Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. © Société Internationale de Chirurgie 2013 |
| abstract_unstemmed |
Background Management of the acute trauma patient is complex, with potential for error and adverse events. Avoidable injuries and deaths are not well understood. Analysis of error incidence, type, and severity can aid in greater understanding of the root causes and guide future development of error reduction strategies. Methods Weekly case review meetings for a UK trauma center were retrospectively reviewed over 1 year. Errors were identified and corroborated with case-note review by a reviewer blinded to any identified events. All events were classified according to the Joint Commission on Accreditation of Healthcare Organisations taxonomy and were typified as structural or process errors and omission or commission errors. Results A total of 1,752 major trauma patients were admitted over the study period, and 169 preventable errors were identified through analysis of case review meetings and case-note review. Clear patient harm was identified in 3.6 % of cases, with risk of harm in 30 %. Most errors occurred during the initial phase of care in the emergency department (51 %) and resulted most commonly in delays (56 %). The majority of errors were identified as process-related (88 %), with 62 % of them considered errors of omission. Conclusions This study reports error incidence in trauma and typifies them according to type and root cause. It identifies process errors and errors of omission in particular as the most common recurring events. Error theory suggests that protocols or checklists may most effectively address these errors. Further study should be prospective and may aid in the development of such interventions. © Société Internationale de Chirurgie 2013 |
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| title_short |
Identifying and Addressing Preventable Process Errors in Trauma Care |
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https://dx.doi.org/10.1007/s00268-013-1917-9 |
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| author2 |
Aggarwal, Rajesh Twaij, Ahmed Batrick, Nicola Jenkins, Michael Darzi, Ara |
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Aggarwal, Rajesh Twaij, Ahmed Batrick, Nicola Jenkins, Michael Darzi, Ara |
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| doi_str |
10.1007/s00268-013-1917-9 |
| up_date |
2024-07-03T19:30:41.575Z |
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