Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems.

Document Type

Article

Publication Date

4-1-2021

Publication Title

Eur J Trauma Emerg Surg

Keywords

washington; seattle; swedish; Delivery of Health Care; Emergency Medicine; Humans; Medical Errors; Quality Improvement; Risk Management

Abstract

BACKGROUND: Critical incident reporting systems (CIRS) are considered to be a valid instrument to identify typical errors in various clinical settings as well as in prehospital emergency medicine. Our aim was to review incidents and errors in the care of trauma patients during the period of emergency trauma room treatment before their transfer to the intensive care unit or the operation room.

METHODS: We screened six open access and German language-based CIRS-platforms on the internet.

RESULTS: We identified 78 critical incidents. They could be divided into four groups: organization related (n = 30), communication related (n = 6), equipment related (n = 28), and medical error (n = 23). Within the category, typical, common, or frequent clusters were identified, such as incomplete trauma team, malfunctioning equipment, or a lack of communication skills. In 12 cases (15.4%), patients were reported to have been harmed, mostly by medical errors. Three reported incidents (3.6%) were considered near-incidents.

CONCLUSIONS: Our results demonstrate that using CIRS is able to reveal individual or rare errors and allows for the identification of systematic errors and deficiencies in the acute care of trauma patients in the trauma room. This may guide quality control and quality improvement measures to be focused on the most common fields of demand.

Clinical Institute

Neurosciences (Brain & Spine)

Department

Emergency Medicine

Department

Neurosciences

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