ANALYSIS OF RECURRENT PROCESS ERRORS LEADING TO PROVIDER-RELATED COMPLICATIONS ON AN ORGANIZED TRAUMA SERVICE - DIRECTIONS FOR CARE IMPROVEMENT

Complications in trauma care occur because of provider-related or pati ent disease-related events. Strictly defined standardized definitions of both types of complications are needed to develop strategies for pr oblem resolution. The frequency and characteristics of 135 disease-rel ated and provider-related complications were examined for a 3-year per iod in a level I university trauma service in all patients meeting Maj or Trauma Outcome Study (MTOS) criteria. Provider-related complication s were analyzed for recurrent process errors to be targeted for correc tive action. Complication events occurred in 2764 of 3327 patients, wi th provider-related complications in 759. Twenty-three percent (175) o fcomplications were judged unjustified and 16 patterns of recurrent pr ocess-of-care errors were identified. Delay in trauma team activation was caused by insensitivity of field triage protocols and inadequate r ecognition of injury patterns. Delays in diagnosis or surgery were cau sed by inadequate performance ofstandard work-up, inadequate recogniti on of injury severity by providers, diagnostic procedure interpretatio n errors, and errors in prioritizing the order of diagnostic procedure s. Errors in technique were attributed to inexperience,haste, unfamili arity with devices, lack of developed institutional techniques, and fa ilure of providers to use recognized endpoints. Errors in judgment wer e attributed to failure to access available patient information, proce eding despite available information, and failure to utilize available care guidelines.Further reduction in provider-related morbidity in an organized trauma systemrequires this type of analysis, which identifie s the need to change the process of care through education or adjustme nt of protocols for standardized care delivery in addition to the trad itional focus on outcomes.