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Pedro G. R. Teixeira, MD; Kenji Inaba, MD, MS; Ali Salim, MD; Peter Rhee, MD, MPH; Carlos Brown, MD; Timothy Browder, MD; Joseph DuBose, MD; Shirley Nomoto, RN, MSN; Demetrios Demetriades, MD, PhD

Arch Surg. 2009;144(6):536-541.

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.

Author Affiliations: Division of Trauma Surgery and Surgical Critical Care, University of Southern California (Drs Teixeira, Inaba, DuBose, and Demetriades and Ms Nomoto), and Department of Surgery, Cedars-Sinai Medical Center (Dr Salim), Los Angeles, California; Division of Trauma, Surgical Critical Care and Emergency Surgery, University of Arizona, Tucson (Dr Rhee); Department of Surgery, University of Texas Medical Branch, Brackenridge Hospital, Austin (Dr Brown); and Division of Trauma and Surgical Critical Care, University of Nevada School of Medicine, Las Vegas (Dr Browder).

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