An Objective Analysis of Process Errors in Trauma Resuscitations

Authors

  • John R. Clarke MD,

    Corresponding author
    1. Department of Surgery (JRC, CZH, TAS) MCP—Hahnemann University, Philadelphia, PA
    2. Department of Computer and Information Science (JRC, BS, ASG, BLW), University of Pennsylvania, Philadelphia, PA
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  • Beverly Spejewski PhD,

    1. Department of Computer and Information Science (JRC, BS, ASG, BLW), University of Pennsylvania, Philadelphia, PA
    2. Department of Radiology (BS), Hospital of the University of Pennsylvania, Philadelphia, PA
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  • Abigail S. Gertner PhD,

    1. Department of Computer and Information Science (JRC, BS, ASG, BLW), University of Pennsylvania, Philadelphia, PA
    2. MITRE Corporation (ASG), Bedford, MA
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  • Bonnie L. Webber PhD,

    1. Department of Computer and Information Science (JRC, BS, ASG, BLW), University of Pennsylvania, Philadelphia, PA
    2. Division of Informatics (BLW), University of Edinburgh, Edinburgh, UK; and Department of Surgery (JAW), Medical College of Wisconsin, Milwaukee, WI.
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  • Catherine Z. Hayward MD,

    1. Department of Surgery (CZH), Thomas Jefferson University, Philadelphia, PA
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  • Thomas A. Santora MD,

    1. Department of Surgery (JRC, CZH, TAS) MCP—Hahnemann University, Philadelphia, PA
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  • David K. Wagner MD,

    1. Department of Emergency Medicine (DKW) MCP—Hahnemann University, Philadelphia, PA
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  • Christopher C. Baker MD,

    1. College of Nursing (CBR), MCP—Hahnemann University, Philadelphia, PA
    2. Department of Surgery (CCB), University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Howard R. Champion MD,

    1. Department of Surgery (JRC, CZH, TAS) MCP—Hahnemann University, Philadelphia, PA
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  • Timothy C. Fabian MD,

    1. Department of Surgery and Department of Military and Emergency Medicine (HRC), Uniformed Services of the Health Sciences, Bethesda, MD
    2. Department of Surgery (TCF), University of Tennessee, Memphis, TN; Department of Surgery (FRL), Henry Ford Hospital, Detroit, MI
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  • Frank R. Lewis Jr. MD,

    1. Department of Surgery (TCF), University of Tennessee, Memphis, TN; Department of Surgery (FRL), Henry Ford Hospital, Detroit, MI
    2. Case Western Reserve University (FRL), Cleveland, OH
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  • Ernest E. Moore MD,

    1. Department of Surgery (EEM), University of Colorado, Denver, CO
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  • John A. Weigelt MD,

    1. Department of Surgery (JAW), University of Minnesota, Minneapolis, MN
    2. Division of Informatics (BLW), University of Edinburgh, Edinburgh, UK; and Department of Surgery (JAW), Medical College of Wisconsin, Milwaukee, WI.
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  • A. Brent Eastman MD,

    1. Department of Surgery (ABE), University of California at San Diego, San Diego, CA. Current affiliations
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  • Cynthia Blank-Reid MSN

    1. Department of Surgery (JRC, CZH, TAS) MCP—Hahnemann University, Philadelphia, PA
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Department of Surgery, MCP—Hahnemann School of Medicine, 3300 Henry Avenue, Philadelphia, PA 19129. Fax: 215-843-1095; e-mail: jclarke@gradient.cis.upenn.edu

Abstract

Abstract. Objective: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. Methods: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. Results: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2.4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5.1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. Conclusions: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

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