DOI: 10.1007/s00268-008-9543-7. Applying Modern Error Theory to the Problem of Missed Injuries in Trauma

Applying Modern Error Theory to the Problem of Missed Injuries in Trauma

10.1007/s00268-008-9543-7

Crossref journal-article

Wiley

World Journal of Surgery (311)

Abstract

AbstractBackgroundModern theory of human error has helped reduce the incidence of adverse events in commercial aviation. It remains unclear whether these lessons are applicable to adverse events in trauma surgery. Missed injuries in a large metropolitan surgical service were prospectively audited and analyzed using a modern error taxonomy to define its applicability to trauma.MethodsA prospective database of all patients who experienced a missed injury during a 6‐month period in a busy surgical service was maintained from July 2006. A missed injury was defined as one that escaped detection from primary assessment to operative exploration. Each missed injury was recorded and categorized. The clinical significance of the error and the level of physician responsible was documented. Errors were divided into planning or execution errors, acts of omission or commission, or violations, slips, and lapses.ResultsA total of 1,024 trauma patients were treated by the surgical services over the 6‐month period from July to December 2006 in Pietermaritzburg. Thirty‐four patients (2.5%) with missed injuries were identified during this period. There were 29 men and 5 women with an average age of 29 years (range: 21–67 years). In 14 patients, errors were related to inadequate clinical assessment. In 11 patients errors involved the misinterpretation of, or failure to respond to radiological imaging. There were 9 cases in which an injury was missed during surgical exploration. Overall mortality was 27% (9 patients). In 5 cases death was directly attributable to the missed injury. The level of the physicians making the error was consultant surgeon (4 cases), resident in training (15 cases), career medical officer (2 cases), referring doctor (6 cases).ConclusionsMissed injuries are uncommon and are made by all grades of staff. They are associated with increased morbidity and mortality. Understanding the pattern of these errors may help develop error‐reduction strategies. Current taxonomies help in understanding the error process, but efforts must be made to develop innovative mechanisms that reduce the potential for error.

Bibliography

Clarke, D. L., Gouveia, J., Thomson, S. R., & Muckart, D. J. J. (2008). Applying Modern Error Theory to the Problem of Missed Injuries in Trauma. World Journal of Surgery, 32(6), 1176â1182. Portico.

Authors 4

D. L. Clarke (first)
J. Gouveia (additional)
S. R. Thomson (additional)
D. J. J. Muckart (additional)

References 27 Referenced 34

{'key': 'e_1_2_6_2_2', 'first-page': '415', 'article-title': 'Unexpected, unsuspected and missed injuries in a paediatric trauma unit', 'volume': '70', 'author': 'Gordon JA', 'year': '1986', 'journal-title': 'S Afr Med J'} / S Afr Med J / Unexpected, unsuspected and missed injuries in a paediatric trauma unit by Gordon JA (1986)
10.1177/000313489906501114
10.1016/0001‐4575(94)90030‐2
10.1016/j.injury.2006.07.044
10.1016/S0039‐6060(96)80030‐4
10.1016/0002‐9610(91)90260‐K
10.1016/S0039-6109(16)45387-9
10.1111/j.2044-8260.1984.tb00635.x
10.1098/rstb.1990.0090
10.1177/088506669000500302
10.1136/qshc.4.2.80
10.1136/bmj.320.7237.768
10.1056/NEJMsa021721
{'key': 'e_1_2_6_15_2', 'first-page': '39', 'article-title': 'Defining medical error', 'volume': '48', 'author': 'Grober ED', 'year': '2005', 'journal-title': 'Can J Surg'} / Can J Surg / Defining medical error by Grober ED (2005)
10.1016/0002‐9610(89)90577‐1
10.1002/bjs.1800841225
{'key': 'e_1_2_6_18_2', 'first-page': '9', 'article-title': 'Quality control in fatally injured patients: the value of the necropsy', 'volume': '159', 'author': 'Barendregt WB', 'year': '1993', 'journal-title': 'Eur J Surg'} / Eur J Surg / Quality control in fatally injured patients: the value of the necropsy by Barendregt WB (1993)
{'key': 'e_1_2_6_19_2', 'first-page': '130', 'article-title': 'Autopsies and death certification in deaths due to blunt trauma: what are we missing?', 'volume': '43', 'author': 'Hodgson NF', 'year': '2000', 'journal-title': 'Can J Surg'} / Can J Surg / Autopsies and death certification in deaths due to blunt trauma: what are we missing? by Hodgson NF (2000)
10.1097/00005373-199710000-00009
10.1016/S0002‐9610(99)80242‐6
10.1016/j.juro.2006.08.003
10.1016/S0002‐9610(05)80152‐7
10.1097/00000658‐199312000‐00013
10.1097/00005373‐199508000‐00007
10.1007/s00268‐001‐0147‐8
10.1007/s00268‐005‐0131‐9
10.1136/qshc.2003.009548

Dates

Type	When
Created	17 years, 5 months ago (March 11, 2008, 11 a.m.)
Deposited	1 year, 7 months ago (Dec. 26, 2023, 6:10 p.m.)
Indexed	2 weeks, 5 days ago (Aug. 6, 2025, 9:15 a.m.)
Issued	17 years, 5 months ago (March 12, 2008)
Published	17 years, 5 months ago (March 12, 2008)
Published Online	17 years, 5 months ago (March 12, 2008)
Published Print	17 years, 2 months ago (June 1, 2008)

Funders 0

None

BibTeX

@article{Clarke_2008, title={Applying Modern Error Theory to the Problem of Missed Injuries in Trauma}, volume={32}, ISSN={1432-2323}, url={http://dx.doi.org/10.1007/s00268-008-9543-7}, DOI={10.1007/s00268-008-9543-7}, number={6}, journal={World Journal of Surgery}, publisher={Wiley}, author={Clarke, D. L. and Gouveia, J. and Thomson, S. R. and Muckart, D. J. J.}, year={2008}, month=mar, pages={1176–1182} }

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