Classification and team response to nonroutine events occurring during pediatric trauma resuscitation.

Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm due to mitigation or chance may 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 errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence. Errors identified using video analysis were classified as errors of omission or commission, and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared. Thirty-nine resuscitations were reviewed, identifying 337 errors (range 2–26 per resuscitation). The most common errors were related to cervical spine stabilization (n=93, 27.6%). Errors of omission (n=135) and commission (n=106) were more common than errors of selection (n=96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p=0.03 and p=0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p=0.004 and p=0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features. Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation. VI prognostic

在儿科创伤复苏过程中，直接导致严重伤害的错误很少见，这限制了不良结果分析在这种情况下用于绩效改进的应用。由于缓解或偶然因素未造成伤害的错误可能有相似的原因，且比导致不良结果的错误更常见。分析这些错误类型是不良结果分析的一种替代方法。本研究的目的是识别儿科创伤复苏过程中的任何类型的错误，并评估团队对其发生的反应。 通过视频分析识别的错误被归类为疏忽错误或作为错误，以及利用创伤专家的意见确定的选择错误。比较了基于患者和事件特征的对错误类型和错误频率的反应。 对39次复苏进行了回顾，识别出337个错误（每次复苏2 - 26个不等）。最常见的错误与颈椎稳定有关（n = 93，27.6%）。疏忽错误（n = 135）和作为错误（n = 106）比选择错误（n = 96）更常见。尽管35.9%的所有错误被察觉，且43.6%的错误之后有弥补措施，但51.3%的错误之后未观察到任何反应（察觉或弥补）。疏忽错误和作为错误比选择错误更常被察觉（分别为40.7%和39.6%对25.0%，p = 0.03和p = 0.04），也更常被弥补（分别为50.4%和47.2%对29.2%，p = 0.004和p = 0.01）。未观察到疏忽错误和作为错误之间的反应差异。错误的数量以及发生的高风险错误的数量不因患者或事件特征而不同。 在儿科创伤复苏过程中错误很常见。团队对大多数错误没有反应，尽管在不同错误类型之间观察到团队反应的差异。确定错误的原因可能是识别在儿科创伤复苏过程中导致不良结果的潜在安全威胁的一种方法。 VI 预后的