An objective analysis of process errors in trauma resuscitations

Objective: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validat ed 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 expert s. The purpose of this article is to describe how this system is now used t o objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. Methods: A chronological narra tive of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each dec ision point and differences were classified by a predetermined scoring syst em from 0 to 100, based on the potential impact on outcome, as critical/non critical/no errors of commission, omission, or procedure selection. Results : Errors in reasoning occurred in 100% of the 97 cases studied, averaging 1 1.9/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 ob serve, bedside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged t o be potentially related to errors of reasoning. Conclusions: Process error s in reasoning were ubiquitous, occurring in every:case, although they were infrequently judged to be potentially related to an adverse outcome. Error s of omission were assessed to be more severe. The most common error was fa ilure to consider, or document, available relevant information in the selec tion of appropriate care.