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PSNet: Patient Safety Network
Journal Article
Study

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.

LaGrone LN, McIntyre LK, Riggle A, et al. J Trauma Acute Care Surg. 2020;89(6):1046-1053.

The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.