Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems.
CIRS
Critical incident
Polytrauma
Trauma
Journal
European journal of trauma and emergency surgery : official publication of the European Trauma Society
ISSN: 1863-9941
Titre abrégé: Eur J Trauma Emerg Surg
Pays: Germany
ID NLM: 101313350
Informations de publication
Date de publication:
Apr 2021
Apr 2021
Historique:
received:
27
08
2018
accepted:
01
04
2019
pubmed:
6
4
2019
medline:
16
10
2021
entrez:
6
4
2019
Statut:
ppublish
Résumé
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. We screened six open access and German language-based CIRS-platforms on the internet. 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. 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.
Sections du résumé
BACKGROUND
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
METHODS
We screened six open access and German language-based CIRS-platforms on the internet.
RESULTS
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
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.
Identifiants
pubmed: 30949741
doi: 10.1007/s00068-019-01128-y
pii: 10.1007/s00068-019-01128-y
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
445-452Références
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