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Classification and Response to Process Errors Occurring During Pediatric Trauma Resuscitation
Rachel B. Webman, MD1, Jennifer Fritzeen1, Paul C. Mullan, MD, MPH2, Faisal G. Qureshi, MD3, Sarah H. Parker, PhD4, Randall S. Burd, MD, PhD1, 1Division of Trauma and Burn Surgery, Children's National Medical Center, Washington DC; 2Division of Emergency Medicine and Trauma Services, Children's National Medical Center, Washington DC; 3Department of General and Thoracic Surgery, Children's National Medical Center, Washington DC; 4National Center for Human Factors in Healthcare, Medstar Institute for Innovation, Washington DC

Abstract:
Purpose:
Errors leading to serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement. Errors not causing harm due to mitigation, prevention or chance 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 resuscitation errors and evaluate responses to their occurrence. Methods: Process errors identified using video analysis were classified as errors of omission or commission and selection errors (ordering or priority errors) using input from experts. The responses to error types were compared (?2 analysis). Results: Among 30 resuscitations, 262 process errors were identified (range 4-25 per event). The most common errors were lapses in c-spine stabilization (n=34, 12.5%) and failure to respond to vital sign abnormalities (n=19, 7.0%). Selection errors (n=98) were more common than errors of omission (n=87) and commission (n=77). Although 35.4% of errors were acknowledged and compensation occurred after 36.7%, 57.6% had no response observed. Errors of commission were more often acknowledged (42.3% vs. 26.2% p=0.02) and compensated for (42.3% vs. 27.1% p=0.03) than selection errors. Response differences between errors of omission and other types were not observed. No error led to an adverse outcome. Conclusions: Process errors are common during pediatric trauma resuscitation. Teams did not respond to most process errors, although differences were observed between error types. Determining causation of process errors may be an approach for identifying risks contributing to adverse outcomes.
Objective:
At the end of this activity, the learner will be able to discuss different types of errors and error responses during pediatric trauma resuscitation and explain that analysis of causal paths of common errors during pediatric trauma resuscitation may be a potential approach for mitigating risks associated with rare adverse events.
Objective Content: Errors of commission: performing a task that was unnecessary or should not have been done -errors of omission: not completing a task that should have been performed -errors of selection: completing the wrong task or tasks in the wrong order -teams do not respond to most pediatric trauma resuscitation errors -adverse events after process errors that occur during pediatric trauma resuscitation are rare -analysis of the response to common process errors during pediatric trauma resuscitation may be an approach leading to an improved understanding of risk conditions associated with adverse outcomes.


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