High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

Riquard Lesley Hensgens; Mostafa El Moumni; Frank F. A IJpma; Jorrit S Harbers; Kaj ten Duis; Klaus W Wendt; Geertje A. M Govaert

Study

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

February 17, 2021

Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46(6):1367-1374.

View more articles from the same authors.

Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.

PubMed citation

Available at

Related Resources From the Same Author(s)

Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study.

June 20, 2018

Rates of surgical consultations after emergency department admission in Black and White Medicare patients.

October 26, 2022

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: a systematic review.

May 5, 2021

Association of low-dose whole-body computed tomography with missed injury diagnoses and radiation exposure in patients with blunt multiple trauma.

February 5, 2020

Optimizing situation awareness to reduce emergency transfers in hospitalized children.

October 20, 2021

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

Sepsis quality in safety-net hospitals: an analysis of Medicare's SEP-1 performance measure.

October 2, 2019

Patient and hospital characteristics associated with delayed diagnosis of appendicitis.

February 1, 2023

Mortality due to hospital-acquired infection after cardiac surgery.

June 1, 2022

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion.

December 2, 2020

Development and expression of a high-reliability organization.

December 1, 2021

Use of an expedited review tool to screen for prior diagnostic error in emergency department patients.

September 28, 2015

Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1).

May 5, 2021

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach.

December 2, 2020

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management.

September 16, 2009

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.

December 1, 2021

Medication errors in the care transition of trauma patients

December 18, 2019

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

Intervention study for the reduction of medication errors in elderly trauma patients.

September 2, 2020

The physiology of failure: identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record.

September 7, 2022

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy.

January 12, 2022

Incidence of prescription errors in patients discharged from the emergency department.

September 22, 2021

The impact of hospital accreditation on the quality of healthcare: a systematic literature review.

October 27, 2021

Emergency department monitor alarms rarely change clinical management: an observational study.

September 16, 2020

Zero preventable deaths after traumatic injury: an achievable goal.

July 12, 2017

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

August 19, 2020

How communication "failed" or "saved the day": counterfactual accounts of medical errors.

February 3, 2021

Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients.

October 12, 2022

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

Association between surgeon technical skills and patient outcomes.

September 9, 2020

Advancing diagnostic safety research: results of a systematic research priority setting exercise.

February 24, 2021

High-fidelity simulation’s impact on clinical reasoning and patient safety: a scoping review.

March 29, 2023

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

March 24, 2021

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events.

May 12, 2021

Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients.

December 8, 2021

Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.

July 22, 2020

The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients.

March 24, 2021

Absence or presence: silent discourse in the operating room and impact on surgical team action.

November 11, 2020

Supporting recovery after adverse events: an essential component of surgeon well-being.

February 10, 2021

A model for improving health care quality for transgender and gender nonconforming patients.

January 23, 2020

Evaluation of postoperative handover using a tool to assess information transfer and teamwork.

May 4, 2011

Risk of medication errors and nurses' quality of sleep: a national cross-sectional web survey study.

September 16, 2020

System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety.

February 10, 2021

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.

March 25, 2020

Reaching the summit of discharge summaries: a quality improvement project.

March 3, 2021

Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event".

August 5, 2020

Assessing patients 2019 experiences with medical injury reconciliation processes: item generation for a novel survey questionnaire.

May 5, 2021

Resilience from a stakeholder perspective: the role of next of kin in cancer care.

September 23, 2020

Trends in adverse event rates in hospitalized patients, 2010-2019.

July 27, 2022

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective.

March 31, 2021

Special Issue on Resilience Engineering and High Reliability Organizations.

August 7, 2019

Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system.

March 23, 2022

Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.

December 2, 2020

Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests.

December 9, 2020

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

Crowd-sourced hospital ratings are correlated with patient satisfaction but not surgical safety.

June 9, 2021

Association of surgeon-patient sex concordance with postoperative outcomes,

December 22, 2021

Frontline assessments of healthcare culture: Safety Attitudes Questionnaire norms and psychometric properties.

March 27, 2005

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.

October 14, 2020

Opioid dependence and overdose after surgery: rate, risk factors, and reasons.

September 21, 2022

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

Root cause analysis for hospital-acquired pressure injury.

August 14, 2019

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.

July 6, 2022

Association of opioid prescribing with opioid consumption after surgery in Michigan.

November 21, 2018

The nurse's role in the causation of compensable injury.

October 12, 2011

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

December 20, 2006

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.

September 30, 2020

Adverse events among emergency department patients with cardiovascular conditions: a multicenter study.

March 10, 2021

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.

September 29, 2021

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

March 24, 2021

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study.

December 21, 2022

The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States.

August 26, 2020

Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators,

October 7, 2020

Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019.

January 4, 2021

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic.

June 8, 2022

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

June 23, 2021

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

The role of automation in complex system failures.

May 11, 2005

Private patient rooms and hospital-acquired methicillin-resistant Staphylococcus aureus: hospital-level analysis of administrative data from the United States.

August 5, 2020

Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.

January 12, 2022

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

April 20, 2022

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

January 11, 2023

Reporting of unsafe conditions at an academic women and children's hospital.

September 29, 2021

National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event.

January 27, 2021

Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers.

January 27, 2021

Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19.

November 17, 2021

Prioritizing patient safety efforts in office practice settings

December 18, 2019

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

Related Resources

Overnight stay in the emergency department and mortality in older patients.

November 29, 2023

WebM&M Cases

Walking Out of a Hospital After Attempted Suicide.

September 27, 2023

WebM&M Cases

Delayed Evaluation of Abdominal Pain in an Elderly Patient.

September 27, 2023

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

August 23, 2023

Improving emergency medicine clinician awareness of prehospital-administered medications.

August 9, 2023

In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.

June 28, 2023

Patient safety in emergency departments: a problem for health care systems? An international survey.

June 21, 2023

WebM&M Cases

The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.

June 14, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

I like what you are saying, but only if I feel safe: psychological safety moderates the relationship between voice and perceived contribution to healthcare team effectiveness.

May 24, 2023

Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety.

May 17, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Reducing diagnostic errors in the emergency department at the time of patient treatment.

March 29, 2023

Closed-loop communication in interprofessional emergency teams: a cross-sectional observation study on the use of closed-loop communication among anesthesia personnel.

March 22, 2023

Misdiagnosis in the emergency department: time for a system solution.

February 8, 2023

ER doctors misdiagnose patients with unusual symptoms.

January 18, 2023

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

December 7, 2022

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Patient Safety Innovations

Journal Article

Study

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

November 16, 2022

Emergency department adverse events detected using the emergency department trigger tool.

August 24, 2022

Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department.

August 17, 2022

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study.

May 18, 2022

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

May 11, 2022

Patient Safety Innovations

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

April 7, 2022

Psychological safety during the test of new work processes in an emergency department.

April 6, 2022

SECUre: a multicentre survey of the safety of emergency care in UK emergency departments.

November 24, 2021

When disasters strike the emergency department: a case series and narrative review.

November 10, 2021

Incidence of prescription errors in patients discharged from the emergency department.

September 22, 2021

See More About The Topic

Emergency Departments

Health Care Providers

Quality and Safety Professionals

Emergency Medicine

Emergency Nursing

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site