A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.
Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication. The program reduced overall medical errors, along with the incidence of several specific types of mistakes, including aspiration pneumonia (caused by entrance of foreign materials into the bronchial tree) and errors during management of shock.