Skip to main content
Erschienen in: European Journal of Trauma and Emergency Surgery 4/2017

12.04.2016 | Original Article

Preventable and potentially preventable deaths in severely injured patients: a retrospective analysis including patterns of errors

verfasst von: C. Schoeneberg, M. Schilling, B. Hussmann, D. Schmitz, S. Lendemans, S. Ruchholtz

Erschienen in: European Journal of Trauma and Emergency Surgery | Ausgabe 4/2017

Einloggen, um Zugang zu erhalten

Abstract

Purpose

Analyzing preventable and potentially preventable deaths is a well-known procedure for improving trauma care. This study analyzes preventable and potentially preventable deaths in German trauma patients.

Methods

Patients aged between 16 and 75 years with an Injury Severity Score >15 who were primary admitted from July 2002 to December 2011 were analyzed in this study. Data from the patients’ hospital records were retrospectively analyzed, and cases were categorized as preventable, potentially preventable, and non-preventable deaths. In addition, trauma management was screened for errors.

Results

2304 patients were admitted from July 2002 to December 2011. 763 of which fulfilled the defined criteria. The mortality rate was 25.3 %. Eight cases (4.2 %) were declared as preventable deaths and 31 cases (16.1 %) as potentially preventable deaths. The most common errors in preclinical trauma care related to airway management. The main clinical error was insufficient hemorrhage control. Fluid overload from infusion was the second most common fault in both.

Conclusions

Preventable and potentially preventable errors still occur in the treatment of severely injured patients. Errors in hemorrhage control and airway management are the most common human treatment errors. The knowledge of these errors could help to improve trauma care in the future.
Literatur
1.
Zurück zum Zitat Ruchholtz S, Lefering R, Paffrath T, et al. Reduction in mortality of severely injured patients in Germany. Dtsch Arztebl Int. 2008;105(13):225–31.PubMedPubMedCentral Ruchholtz S, Lefering R, Paffrath T, et al. Reduction in mortality of severely injured patients in Germany. Dtsch Arztebl Int. 2008;105(13):225–31.PubMedPubMedCentral
3.
Zurück zum Zitat Gertner HR, Baker SP, Rutherford RB, et al. Evaluation of the management of vehicular fatalities secondary to abdominal injury. J Trauma. 1972;12(5):425–31.CrossRefPubMed Gertner HR, Baker SP, Rutherford RB, et al. Evaluation of the management of vehicular fatalities secondary to abdominal injury. J Trauma. 1972;12(5):425–31.CrossRefPubMed
4.
Zurück zum Zitat West JG, Trunkey DD, Lim RC. Systems of trauma care. A study of two counties. Arch Surg. 1979;114(4):455–60.CrossRefPubMed West JG, Trunkey DD, Lim RC. Systems of trauma care. A study of two counties. Arch Surg. 1979;114(4):455–60.CrossRefPubMed
5.
Zurück zum Zitat West JG, Cales RH, Gazzaniga AB. Impact of regionalization. The Orange County experience. Arch Surg. 1983;118(6):740–4.CrossRefPubMed West JG, Cales RH, Gazzaniga AB. Impact of regionalization. The Orange County experience. Arch Surg. 1983;118(6):740–4.CrossRefPubMed
6.
Zurück zum Zitat Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma. 2000;49(2):237–45.CrossRefPubMed Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma. 2000;49(2):237–45.CrossRefPubMed
7.
Zurück zum Zitat Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma. 2001;51(5):824–32 (discussion 832–4).CrossRefPubMed Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma. 2001;51(5):824–32 (discussion 832–4).CrossRefPubMed
8.
Zurück zum Zitat Reason JT. Understanding adverse events: the human factor. In: Vincent C, editor. Clinical risk management: enhancing patient safety. London: BMJ Books; 2001. p. 6–30. Reason JT. Understanding adverse events: the human factor. In: Vincent C, editor. Clinical risk management: enhancing patient safety. London: BMJ Books; 2001. p. 6–30.
10.
Zurück zum Zitat Spahn DR, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2):R76.CrossRefPubMedPubMedCentral Spahn DR, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2):R76.CrossRefPubMedPubMedCentral
11.
Zurück zum Zitat Schoeneberg C, Schilling M, Keitel J, et al. Trauma Network, Trauma Registry of the DGU(R), Whitebook, S3 guideline on treatment of polytrauma/severe injuries—an approach for validation by a retrospective analysis of 2304 patients (2002–2011) of a level 1 trauma centre. Zentralbl Chir. 2014 [epub ahead of print]. doi:10.1055/s-0033-1360225. Schoeneberg C, Schilling M, Keitel J, et al. Trauma Network, Trauma Registry of the DGU(R), Whitebook, S3 guideline on treatment of polytrauma/severe injuries—an approach for validation by a retrospective analysis of 2304 patients (2002–2011) of a level 1 trauma centre. Zentralbl Chir. 2014 [epub ahead of print]. doi:10.​1055/​s-0033-1360225.
13.
Zurück zum Zitat Kleber C, Giesecke MT, Tsokos M, et al. Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg. 2013;37(5):1154–61.CrossRefPubMed Kleber C, Giesecke MT, Tsokos M, et al. Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg. 2013;37(5):1154–61.CrossRefPubMed
14.
Zurück zum Zitat Settervall CH, Domingues CDA, Sousa RM, et al. Preventable trauma deaths. Rev Saude Publica. 2012;46(2):367–75.CrossRefPubMed Settervall CH, Domingues CDA, Sousa RM, et al. Preventable trauma deaths. Rev Saude Publica. 2012;46(2):367–75.CrossRefPubMed
15.
Zurück zum Zitat Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63(6):1338–46 (discussion 1346–7).CrossRefPubMed Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63(6):1338–46 (discussion 1346–7).CrossRefPubMed
16.
Zurück zum Zitat Davis JW, Hoyt DB, McArdle, et al. An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma. 1992;32(5):660–5 (discussion 665–6).CrossRefPubMed Davis JW, Hoyt DB, McArdle, et al. An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma. 1992;32(5):660–5 (discussion 665–6).CrossRefPubMed
17.
Zurück zum Zitat Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg. 2006;244(3):371–80.PubMedPubMedCentral Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg. 2006;244(3):371–80.PubMedPubMedCentral
18.
Zurück zum Zitat Anderson ID, Woodford M, de Dombal FT, et al. Retrospective study of 1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed). 1988;296(6632):1305–8.CrossRef Anderson ID, Woodford M, de Dombal FT, et al. Retrospective study of 1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed). 1988;296(6632):1305–8.CrossRef
19.
Zurück zum Zitat Kreis DJ, Plasencia G, Augenstein D, et al. Preventable trauma deaths: Dade County, Florida. J Trauma. 1986;26(7):649–54.CrossRefPubMed Kreis DJ, Plasencia G, Augenstein D, et al. Preventable trauma deaths: Dade County, Florida. J Trauma. 1986;26(7):649–54.CrossRefPubMed
20.
Zurück zum Zitat Stocchetti N, Pagliarini G, Gennari M, et al. Trauma care in Italy: evidence of in-hospital preventable deaths. J Trauma. 1994;36(3):401–5.CrossRefPubMed Stocchetti N, Pagliarini G, Gennari M, et al. Trauma care in Italy: evidence of in-hospital preventable deaths. J Trauma. 1994;36(3):401–5.CrossRefPubMed
21.
Zurück zum Zitat Zafarghandi M, Modaghegh MS, Roudsari BS. Preventable trauma death in Tehran: an estimate of trauma care quality in teaching hospitals. J Trauma. 2003;55(3):459–65.CrossRefPubMed Zafarghandi M, Modaghegh MS, Roudsari BS. Preventable trauma death in Tehran: an estimate of trauma care quality in teaching hospitals. J Trauma. 2003;55(3):459–65.CrossRefPubMed
22.
Zurück zum Zitat Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420–5.PubMed Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420–5.PubMed
23.
Zurück zum Zitat Schoeneberg C, Schilling M, Burggraf M, et al. Reduction in mortality in severely injured patients following the introduction of the “Treatment of patients with severe and multiple injuries” guideline of the German society of trauma surgery—a retrospective analysis of a level 1 trauma center (2010–2012). Injury. 2014;45(3):635–8.CrossRefPubMed Schoeneberg C, Schilling M, Burggraf M, et al. Reduction in mortality in severely injured patients following the introduction of the “Treatment of patients with severe and multiple injuries” guideline of the German society of trauma surgery—a retrospective analysis of a level 1 trauma center (2010–2012). Injury. 2014;45(3):635–8.CrossRefPubMed
24.
Zurück zum Zitat Pape H, Grimme K, van Griensven M, et al. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma. 2003;55(1):7–13.CrossRefPubMed Pape H, Grimme K, van Griensven M, et al. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma. 2003;55(1):7–13.CrossRefPubMed
25.
Zurück zum Zitat Hussmann B, Lefering R, Waydhas C, et al. Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury. 2013;44(5):611–7.CrossRefPubMed Hussmann B, Lefering R, Waydhas C, et al. Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury. 2013;44(5):611–7.CrossRefPubMed
26.
Zurück zum Zitat Haut ER, Kalish BT, Cotton BA, et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Ann Surg. 2011;253(2):371–7.CrossRefPubMed Haut ER, Kalish BT, Cotton BA, et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Ann Surg. 2011;253(2):371–7.CrossRefPubMed
27.
Zurück zum Zitat Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70(2):398–400.CrossRefPubMed Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70(2):398–400.CrossRefPubMed
28.
Zurück zum Zitat Schoeneberg C, Schilling M, Probst T, et al. Preventable and potentially preventable deaths in severely injured elderly patients: a single-center retrospective data analysis of a German Trauma Center. World J Surg. 2014;38:3125–32.CrossRefPubMed Schoeneberg C, Schilling M, Probst T, et al. Preventable and potentially preventable deaths in severely injured elderly patients: a single-center retrospective data analysis of a German Trauma Center. World J Surg. 2014;38:3125–32.CrossRefPubMed
29.
Zurück zum Zitat Cobas MA, De la Pena MA, Manning R, et al. Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg. 2009;109(2):489–93.CrossRefPubMed Cobas MA, De la Pena MA, Manning R, et al. Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg. 2009;109(2):489–93.CrossRefPubMed
30.
Zurück zum Zitat Albrecht E, Yersin B, Spahn DR, et al. Success rate of airway management by residents in a pre-hospital emergency setting: a retrospective study. Eur J Trauma. 2006;32(6):516–22.CrossRef Albrecht E, Yersin B, Spahn DR, et al. Success rate of airway management by residents in a pre-hospital emergency setting: a retrospective study. Eur J Trauma. 2006;32(6):516–22.CrossRef
31.
Zurück zum Zitat Nakstad AR, Heimdal H, Strand T, et al. Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service. Am J Emerg Med. 2011;29(6):639–44.CrossRefPubMed Nakstad AR, Heimdal H, Strand T, et al. Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service. Am J Emerg Med. 2011;29(6):639–44.CrossRefPubMed
32.
Zurück zum Zitat Rognas L, Hansen TM, Kirkegaard H, et al. Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med. 2013;21:58.CrossRefPubMedPubMedCentral Rognas L, Hansen TM, Kirkegaard H, et al. Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med. 2013;21:58.CrossRefPubMedPubMedCentral
33.
Zurück zum Zitat Deutsche Gesellschaft für Unfallchirurgie. Whitebook Medical Care of the Severely Injured—second revised and updated edition. Orthop Traumatol Commun News. 2012;Supplement 1:1–63. Deutsche Gesellschaft für Unfallchirurgie. Whitebook Medical Care of the Severely Injured—second revised and updated edition. Orthop Traumatol Commun News. 2012;Supplement 1:1–63.
Metadaten
Titel
Preventable and potentially preventable deaths in severely injured patients: a retrospective analysis including patterns of errors
verfasst von
C. Schoeneberg
M. Schilling
B. Hussmann
D. Schmitz
S. Lendemans
S. Ruchholtz
Publikationsdatum
12.04.2016
Verlag
Springer Berlin Heidelberg
Erschienen in
European Journal of Trauma and Emergency Surgery / Ausgabe 4/2017
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-016-0670-9

Weitere Artikel der Ausgabe 4/2017

European Journal of Trauma and Emergency Surgery 4/2017 Zur Ausgabe

Arthropedia

Grundlagenwissen der Arthroskopie und Gelenkchirurgie. Erweitert durch Fallbeispiele, Videos und Abbildungen. 
» Jetzt entdecken

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.