ERROR REDUCTION IN TRAUMA CARE: LESSONS FROM AN ANONYMIZED, NATIONAL, MULTICENTER MORTALITY REPORTING SYSTEM.

BACKGROUND Twenty years ago, the landmark report To Err is Human, illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Yet rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) developed a voluntary Mortality Reporting System (MRS) to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the MRS. METHODS An anonymous structured web-based reporting template based on JCAHO taxonomy was made available to trauma centers participating in TQIP to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions. RESULTS Over a 2-yr period, 395 deaths were reviewed. 33.7% of mortalities were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%) and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers couldn't identify a specific strategy to prevent future harm. CONCLUSIONS Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm. LEVEL OF EVIDENCE VStudy TypeCase series.