Preventable morbidity at a mature trauma center

Pedro G R Teixeira, Kenji Inaba, Ali Salim, Peter Rhee, Carlos Brown, Timothy Browder, Joseph DuBose, Shirley Nomoto, Demetrios Demetriades
Archives of Surgery 2009, 144 (6): 536-41; discussion 541-2

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.

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