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, Randall S. Burd

Research output: Contribution to journalArticle

10 Citations (Scopus)

Abstract

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. LEVEL OF EVIDENCE Therapeutic study, level III.

Original languageEnglish (US)
Pages (from-to)666-673
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume81
Issue number4
DOIs
StatePublished - Oct 1 2016

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Resuscitation
Pediatrics
Wounds and Injuries
Causality
Spine
Safety

Keywords

  • Clinical practice patterns
  • errors, medical
  • healthcare quality assessment
  • team performance
  • trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation. / Webman, Rachel B.; Fritzeen, Jennifer L.; Yang, Jaewon; Ye, Grace F.; Mullan, Paul C.; Qureshi, Faisal G.; Parker, Sarah H.; Sarcevic, Aleksandra; Marsic, Ivan; Burd, Randall S.

In: Journal of Trauma and Acute Care Surgery, Vol. 81, No. 4, 01.10.2016, p. 666-673.

Research output: Contribution to journalArticle

Webman, RB, Fritzeen, JL, Yang, J, Ye, GF, Mullan, PC, Qureshi, FG, Parker, SH, Sarcevic, A, Marsic, I & Burd, RS 2016, 'Classification and team response to nonroutine events occurring during pediatric trauma resuscitation', Journal of Trauma and Acute Care Surgery, vol. 81, no. 4, pp. 666-673. https://doi.org/10.1097/TA.0000000000001196
Webman, Rachel B. ; Fritzeen, Jennifer L. ; Yang, Jaewon ; Ye, Grace F. ; Mullan, Paul C. ; Qureshi, Faisal G. ; Parker, Sarah H. ; Sarcevic, Aleksandra ; Marsic, Ivan ; Burd, Randall S. / Classification and team response to nonroutine events occurring during pediatric trauma resuscitation. In: Journal of Trauma and Acute Care Surgery. 2016 ; Vol. 81, No. 4. pp. 666-673.
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T1 - Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

AU - Webman, Rachel B.

AU - Fritzeen, Jennifer L.

AU - Yang, Jaewon

AU - Ye, Grace F.

AU - Mullan, Paul C.

AU - Qureshi, Faisal G.

AU - Parker, Sarah H.

AU - Sarcevic, Aleksandra

AU - Marsic, Ivan

AU - Burd, Randall S.

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N2 - BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. LEVEL OF EVIDENCE Therapeutic study, level III.

AB - BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. LEVEL OF EVIDENCE Therapeutic study, level III.

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