Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo / American vs. European Trauma Centers: A Comparison of Preventable Deaths

Introducción: El objetivo del estudio es comparar la calidad asistencial de un trauma center americano (USC) vs. un centro equivalente de referencia europeo (SRC) en España, a través del análisis de la mortalidad evitable. Métodos: Estudio comparativo que evalúa pacientes politraumatizados mayores de 16 años que han sido exitus durante su hospitalización. Se han identificado las muertes evitables o potencialmente evitables, analizando los errores en el manejo, clasificándolos según la taxonomía de la Joint Comission. Resultados: La incidencia de mortalidad evitable y potencialmente evitable fue del 7,7% en el USC, y del 13,8% en el SRC. Según la taxonomía de la Joint Comission, el principal tipo de error fue clínico en ambos centros, debido a errores de intervención (tratamiento). Los errores ocurren en urgencias y fueron causados por médicos. En el USC, el 73% de los errores fue de tipo terapéutico comparado con el 59% en el SRC (p = 0,06). El SRC tuvo un 41% de errores diagnósticos vs. solo el 18% en el USC (p = 0,001). En ambos centros, el principal tipo de error fue humano, siendo tipo knowledge-based el más frecuente en el USC (44%) vs. rule-based en el SRC (58%) (p < 0,001). Conclusiones: El uso de un lenguaje común para analizar los errores de manejo es una clave esencial para establecer puntos de referencia estándares y universales. Comparando la calidad asistencial de un trauma center americano con la de un centro de referencia español, hemos detectado unos errores evitables extraordinariamente parecidos. Se han hallado más errores diagnósticos y de tipo ruled-based en el centro español (AU)

Introduction: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. Methods: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. Results: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P = .06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was "knowledge-based" (44%). In contrast, at the SRC center the most common errors were "rule-based" (58%) (P < .001). Conclusions: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and "ruled-based" errors have been found in the Spanish center (AU)

American vs. European Trauma Centers: A Comparison of Preventable Deaths. / Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo.

INTRODUCTION: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. METHODS: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. RESULTS: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001). CONCLUSIONS: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center.

Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology.

BACKGROUND: Benchmarking and classification of avoidable errors in trauma care are difficult as most reports classify errors using variable locally derived schemes. We sought to classify errors in a large trauma population using standardized Joint Commission taxonomy. METHODS: All preventable/potentially preventable deaths identified at an urban, level-1 trauma center (January 2002 to December 2010) were abstracted from the trauma registry. Errors deemed avoidable were classified within the 5-node (impact, type, domain, cause, and prevention) Joint Commission taxonomy. RESULTS: Of the 377 deaths in 11,100 trauma contacts, 106 (7.7%) were preventable/potentially preventable deaths related to 142 avoidable errors. Most common error types were in clinical performance (inaccurate diagnosis). Error domain involved primarily the emergency department (therapeutic interventions), caused mostly by knowledge deficits. Communication improvement was the most common mitigation strategy. CONCLUSION: Standardized classification of errors in preventable trauma deaths most often involve clinical performance in the early phases of care and can be mitigated with universal strategies.

Maintaining patient throughput on an evolving trauma/emergency surgery service.

BACKGROUND: The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized. METHODS: An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest. RESULTS: The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01). CONCLUSIONS: The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

Update on the National Patient Safety Goals - changes for 2006.

Compliance with the NPSGs is mandatory for an organization that seeks JCAHO accreditation. Beyond compliance with goals simply for survey purposes, hospitals that provide care to trauma patients should attempt to make the care of the patient as safe as possible by anticipating problems and complications, and avoiding them if possible.