RT Journal
A1 Teixeira PR, Inaba K, Salim A, et al
T1 PReventable morbidity at a mature trauma center
JF Archives of Surgery
JO Archives of Surgery
YR 2009
FD June 1
VO 144
IS 6
SP 536
OP 541
DO 10.1001/archsurg.2009.82
UL http://dx.doi.org/10.1001/archsurg.2009.82
AB Objective 
    To analyze the preventable and potentially preventable complications occurring at a mature level I trauma center.Design 
    Retrospective review.Setting 
    Academic level I trauma center.Patients 
    The study included 35 311 trauma registry patients.Main Outcome Measures 
    The cause, effect on outcome, preventability (preventable, potentially preventable, or nonpreventable), and loop closure recommendations for all preventable and potentially preventable complications, and clinical data related to each complication retrieved from the trauma registry and individual medical records.Results 
    Over the 8-year study, 35 311 trauma registry patients experienced 2560 complications. Three hundred fifty-one patients (0.99% of all patients) had 403 preventable or potentially preventable complications. The most common preventable or potentially preventable complications were unintended extubation (63 patients [17% of complications]), surgical technical failures (61 patients [15% of complications]), missed injuries (58 patients [14% of complications]), and intravascular catheter–related complications (48 patients [12% of complications]). These complications were clinically relevant; 258 (64% of complications) resulted in a change in management, including 61 laparotomies, 52 reintubations, 41 chest tube insertions, and 19 vascular interventions.Conclusions 
    The incidence of preventable or potentially preventable complications at an academic level I trauma center is low. These complications often require a change in management and cluster in 4 major categories (ie, unintended extubation, surgical technical failures, missed injuries, and intravascular catheter–related complications) that must be recognized as critical areas for quality improvement initiatives.