ArticleAnnals of surgery2006
Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.
Article in Annals of surgery, 2006. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 154 papers, 3 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
154 citing papers in PubMed, 3 syntheses or guidelines pooled it, 448 citations in OpenAlex.
- Freeze-dried plasma for major trauma - Systematic review and meta-analysis.The journal of trauma and acute care surgery · 2021Pooled it
- Trauma quality indicators: internationally approved core factors for trauma management quality evaluation.World journal of emergency surgery : WJES · 2021Pooled it
- Pooled it
- Preventable mortality in geriatric hip fracture inpatients.The bone & joint journal · 2014Trial
- Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation.Injury · 2014Trial
- Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial.Annals of surgery · 2011Trial
- Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients).Annals of surgery · 2007Trial
- Clinical outcomes and opportunities for improvement across modified trauma quality improvement cohorts: a registry-based cohort study.Scandinavian journal of trauma, resuscitation and emergency medicine · 2026Article
- Critically Ill Patients Presenting to the Emergency Department; Outcome Review in a Tertiary Care Center.Saudi medical journal · 2026Article
- Game Elements in Military Trauma Care Education: Systematic Review.JMIR serious games · 2026Review
- Time-critical care gaps and systemic delays linked to higher mortality in severe trauma patients in Tanzania.BMC emergency medicine · 2026Observational
- Artificial Intelligence documentation in trauma resuscitation: efficiency requires guardrails.Trauma surgery & acute care open · 2026Article
- Breaking the silence: communication failures are the leading errors identified in 10-years of trauma morbidity and mortality conferences.European journal of trauma and emergency surgery : official publication of the European Trauma Society · 2025Article
- The Norwegian national trauma registry: development process and essential data insights.Scandinavian journal of trauma, resuscitation and emergency medicine · 2025Article
- Incorporating red blanket protocol within code crimson: Streamlining definitive trauma care amid the chaos.World journal of critical care medicine · 2025Article
- Incidence of opportunities for improvement in trauma patient care: a retrospective registry-based study.Trauma surgery & acute care open · 2025Article
- 'How are we going to harm the next trauma patient?' Trauma care providers' perspective on potential harm to trauma patients.Trauma surgery & acute care open · 2025Article
- Addressing Teamwork Delays during Life-Saving Interventions through an Activity Theory-Informed Analysis.Proceedings of the ACM on human-computer interaction · 2025Article
- [Focus emergency medicine 2023/2024-Summary of selected studies in emergency medicine].Die Anaesthesiologie · 2024Review
- Update on the pathophysiology and management of acute trauma hemorrhage and trauma-induced coagulopathy based upon viscoelastic testing.Clinical and experimental emergency medicine · 2024Article
94 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveTo identify patterns of errors contributing to inpatient trauma deaths.
methodsAll inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data.
resultsIn 9 years, there were 44,401 trauma patient admissions and 2,594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths.
conclusionsPreventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.
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What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.