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Classification and team response to nonroutine events occurring during pediatric trauma resuscitation
Journal article   Open access   Peer reviewed

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

Rachel B Webman, Jennifer L Fritzeen, JaeWon Yang, Grace F Ye, Paul C Mullan, Faisal G Qureshi, Sarah H Parker, Aleksandra Sarcevic, Ivan Marsic and Randall S Burd
The journal of trauma and acute care surgery, v 81(4), pp 666-673
Oct 2016
DOI: https://doi.org/10.1097/TA.0000000000001196
PMID: 27648769
Featured in Collection :   UN Sustainable Development Goals @ Drexel
url
https://europepmc.org/articles/pmc5031245View
Accepted (AM)Open Access (License Unspecified),  Open

Abstract

Medical Errors - classification Patient Care Team - standards Resuscitation - standards Trauma Centers - organization & administration Humans Video Recording Female Male Pediatrics - standards Hospitals, Pediatric - organization & administration Child Maryland
Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm because of mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence. Errors identified using video analysis were classified as errors of omission or commission and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared. Thirty-nine resuscitations were reviewed, identifying 337 errors (range, 2-26 per resuscitation). The most common errors were related to cervical spine stabilization (n = 93, 27.6%). Errors of omission (n = 135) and commission (n = 106) were more common than errors of selection (n = 96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p = 0.03 and p = 0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p = 0.004 and p = 0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features. Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation. Therapeutic study, level III.

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7 Record Views
25 citations in Web of Science
24 citations in Scopus

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UN Sustainable Development Goals (SDGs)

This publication has contributed to the advancement of the following goals:

#3 Good Health and Well-Being

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Collaboration types
Domestic collaboration
Web of Science research areas
Critical Care Medicine
Surgery
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