Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.

Russell L Gruen; Gregory J Jurkovich; Lisa K McIntyre; Hugh M Foy; Ronald V Maier

Study

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.

November 1, 2006

Gruen RL, Jurkovich GJ, McIntyre LK, et al. Transactions of the .. Meeting of the American Surgical Association. 2006;124.

View more articles from the same authors.

The researchers audited 9 years of records related to inpatient trauma deaths and found identifiable error patterns that can be used to target error interventions.

Available at

Free full text

PubMed citation

Related Resources From the Same Author(s)

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

March 24, 2021

Gossypiboma: tales of lost sponges and lessons learned.

September 1, 2010

Remedies sought and obtained in healthcare complaints.

September 7, 2011

Interventions for reducing wrong-site surgery and invasive procedures.

November 14, 2012

Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE).

October 17, 2012

Professionalism in medicine: results of a national survey of physicians.

December 12, 2007

Inflammation and the Host Response to Injury, a Large-Scale Collaborative Project: patient-oriented research core—standard operating procedures for clinical care. II. Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma patient.

May 31, 2006

Strategies for preventing distractions and interruptions in the OR.

June 19, 2013

Quality improvement: Universal Protocol use in office-based gastrointestinal procedure units.

January 9, 2013

Overdiagnosis of coronary artery disease detected by coronary computed tomography angiography: a teachable moment.

November 23, 2016

Intravenous infusion safety technology: return on investment.

August 26, 2009

Risk factors for adverse drug events: a 10-year analysis.

June 8, 2005

Health literacy and quality: focus on chronic illness care and patient safety.

November 18, 2009

Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.

May 22, 2013

Implementation of the World Health Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures.

November 30, 2016

Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists.

March 3, 2010

Parental misinterpretations of over-the-counter pediatric cough and cold medication labels.

July 1, 2009

Patient safety: where is nursing education?

March 14, 2007

A decade of preventing harm.

June 19, 2019

Dispensing error rate in a highly automated mail-service pharmacy practice.

November 23, 2005

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

December 8, 2010

What context features might be important determinants of the effectiveness of patient safety practice interventions?

June 29, 2011

The role of theory in research to develop and evaluate the implementation of patient safety practices.

January 30, 2005

Portable advanced medical simulation for new emergency department testing and orientation.

May 10, 2006

How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research.

May 4, 2011

'Just culture': improving safety by achieving substantive, procedural and restorative justice.

May 25, 2016

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.

March 1, 2017

A framework for classifying patient safety practices: results from an expert consensus process.

January 30, 2005

Review article: improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient.

November 13, 2013

Do user-applied safety labels on medication syringes reduce the incidence of medication errors during rapid medical response intervention for deteriorating patients in wards? A systematic search and review.

September 11, 2019

A just culture after Mid Staffordshire.

March 26, 2014

Laparoscopic bile duct injury: understanding the psychology and heuristics of the error.

February 11, 2009

Creating a framework to integrate residency program and medical center approaches to quality improvement and patient safety training

January 13, 2021

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Junior doctors' shifts and sleep deprivation.

June 29, 2005

Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods.

January 21, 2015

Use of a public health law framework to improve medication safety by anesthesia providers.

March 20, 2019

Disclosure and apology: nursing and risk management working together.

August 8, 2018

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Nurses' attitudes to a medical emergency team service in a teaching hospital.

December 20, 2006

Standards for patient monitoring during general anesthesia at Harvard Medical School.

March 6, 2005

Prevention by design: construction and renovation of health care facilities for patient safety and infection prevention.

September 28, 2016

Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.

October 21, 2009

Integrating incident reporting into an electronic patient record system.

March 14, 2007

Synergy for patient safety and quality: academic and service partnerships to promote effective nurse education and clinical practice.

February 15, 2012

Development of a training program for bar-code–assisted medication administration in inpatient pharmacy.

October 27, 2010

False dawns and new horizons in patient safety research and practice.

December 20, 2017

Systematic biases in group decision-making: implications for patient safety.

November 5, 2014

Raising and responding to frontline concerns in healthcare.

September 11, 2019

Testing alertness of emergency physicians: a novel quantitative measure of alertness and implications for worker and patient care.

January 15, 2020

Misunderstanding of prescription drug warning labels among patients with low literacy.

June 7, 2006

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

September 24, 2014

Point-of-care testing, medical error, and patient safety: a 2007 assessment.

August 1, 2007

Identification errors in pathology and laboratory medicine.

March 6, 2005

Appropriate use of medical interpreters.

November 19, 2014

Standardizing hand-off processes.

January 3, 2007

Communication errors in dispatch of air medical transport.

December 8, 2010

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

September 22, 2021

Use of administrative data to find substandard care: validation of the complications screening program.

October 26, 2005

The global burden of unsafe medical care: analytic modelling of observational studies.

October 2, 2013

Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.

February 24, 2010

Coping and recovery in surgical residents after adverse events: the second victim phenomenon.

April 20, 2022

A multiple-drawer medication layout problem in automated dispensing cabinets.

December 19, 2012

Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence.

July 15, 2015

Challenges faced in providing safe care in rural perinatal settings.

November 25, 2009

Simple strategies to avoid medication errors.

March 21, 2007

New solutions to reduce wrong route medication errors.

December 13, 2017

Barcode medication administration work-arounds: a systematic review and implications for nurse executives.

November 27, 2013

The effects of bar-coding technology on medication errors: a systematic literature review.

April 19, 2017

Innovative teaching in situational awareness.

June 24, 2015

Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.

August 13, 2014

A report of information technology and health deficiencies in U.S. nursing homes.

September 8, 2021

Structural racism in behavioral health presentation and management.

May 17, 2023

Health information technologies: from hazardous to the dark side.

August 3, 2016

Half-life of a printed handoff document.

May 11, 2016

The tension between promoting mobility and preventing falls in the hospital.

May 10, 2017

Early adopters of computerized physician order entry in hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports on quality.

April 1, 2009

Design and implementation of an ICU incident registry.

November 1, 2006

Electronic health record alert–related workload as a predictor of burnout in primary care providers.

August 30, 2017

Error reduction through team leadership: applying aviation's CRM model in the OR.

February 22, 2006

Assessing the performance of aging surgeons.

January 30, 2019

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study.

November 16, 2011

Critical events during land-based interfacility transport.

February 12, 2014

Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research.

January 8, 2014

Frequency of medication administration timing error in hospitals: a systematic review.

March 29, 2023

Performance of a fail-safe system to follow up abnormal mammograms in primary care.

September 8, 2010

Epidemiology of adverse events in air medical transport.

October 1, 2008

Reducing adverse events in blood transfusion.

October 5, 2005

Medical-surgical nurse leaders' experiences with safety culture: an inductive qualitative descriptive study.

November 9, 2022

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Effectiveness of interventions to improve adverse drug reaction reporting by healthcare professionals over the last decade: A systematic review

December 11, 2019

There is no such thing as a "nonjudgmental" debriefing: a theory and method for debriefing with good judgment.

April 12, 2006

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.

March 14, 2012

Momentary interruptions can derail the train of thought.

January 30, 2013

Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.

May 10, 2023

Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears.

March 6, 2005

Overnight and postcall errors in medication orders.

July 20, 2005

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

March 25, 2020

Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.

October 3, 2018

Related Resources

So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization.

July 5, 2023

Identification of patient safety threats in a post-intensive care clinic.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Increased mortality and costs associated with adverse events in intensive care unit patients.

April 6, 2022

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.

March 23, 2022

Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice.

March 16, 2022

Care transition of trauma patients: processes with articulation work before and after handoff.

February 16, 2022

Analyzing diagnostic errors in the acute setting: a process-driven approach.

October 20, 2021

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

October 6, 2021

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

August 25, 2021

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

February 17, 2021

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.

February 10, 2021

Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis.

January 13, 2021

Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.

February 12, 2020

Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan.

December 4, 2019

Unintended discontinuation of medication following hospitalisation: a retrospective cohort study.

June 19, 2019

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics.

June 7, 2017

Finding diagnostic errors in children admitted to the PICU.

February 8, 2017

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

August 17, 2016

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial.

March 18, 2015

Diagnostic errors in the pediatric and neonatal ICU: a systematic review.

March 4, 2015

Participation in EHR based simulation improves recognition of patient safety issues.

December 10, 2014

An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.

November 26, 2014

Blink or think: can further reflection improve initial diagnostic impressions?

November 19, 2014

Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.

November 5, 2014

Factors associated with post-intensive care unit adverse events: a clinical validation study.

October 29, 2014

The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.

October 22, 2014

A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors.

September 24, 2014

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.

September 3, 2014

See More About The Topic

Quality and Safety Professionals

Critical Care

Diagnostic Errors

Discontinuities, Gaps, and Hand-Off Problems

Epidemiology of Errors and Adverse Events

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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