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Nikouline A, Quirion A, Jung JJ, et al. CJEM. 2021;23:537–546.
Trauma resuscitation is a complex, specialized care process with a high risk for errors. This systematic review identified 39 unique errors occurring in trauma resuscitation involving emergency medical services (EMS) handover; airway management; inadequate assessment and/or management of injuries; inadequate monitoring, transfusion/blood-related errors; team communication errors; procedure-related errors; or errors in disposition.
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2021;17:e898-e903.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).
Jones A, Johnstone M-J. Aust Crit Care. 2017;30:219-223.
This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.