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Open Access

Defining adverse events during trauma resuscitation: a modified RAND Delphi study

Brodie Nolan, Andrew Petrosoniak, Christopher M Hicks, Michael W Cripps, Ryan P Dumas
DOI: 10.1136/tsaco-2021-000805 Published 19 October 2021
Brodie Nolan
1Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
2Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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  • ORCID record for Brodie Nolan
Andrew Petrosoniak
1Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
2Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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Christopher M Hicks
1Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
2Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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Michael W Cripps
3Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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Ryan P Dumas
4Department of Surgery, UT Southwestern Medical, Dallas, Texas, USA
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Article Figures & Data

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  • Figure 1
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    Figure 1

    Delphi study overview. AE, adverse event.

Tables

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  • Table 1

    Demographic characteristics of participants

    Professionn (%)
    Trauma surgeon11 (50.0)
    Emergency medicine physician5 (22.8)
    Nurse4 (18.2)
    Anesthesiologist1 (4.5)
    Respiratory therapist1 (4.5)
    Years in practice, mean (SD)8.2 (6.6)
    Country of practicen (%)
    Canada15 (68.2)
    USA7 (31.8)
  • Table 2

    Final taxonomy of adverse events that occur during acute trauma resuscitation

    Airway and breathing
    • Failure to identify need for supplemental oxygen.

    • Unanticipated loss of airway.

    • Unintentional delay in intubation (>5 min).

    • Unsuccessful intubation attempt.

    • Malpositioned endotracheal tube.

    • Aspiration event.

    • Ventilator malfunction.

    • Failure to identify need for chest tube.

    • Failure to perform surgical airway when indicated.

    • Administration of paralytics prior to all teams ready.

    • Failure to discuss, anticipate, or treat hemodynamic instability prior to intubation.

    Circulation
    • Failure to obtain peripheral or central venous access within 5 min of first attempt.

    • Failure to draw bloodwork within 10 min of arrival.

    • Delay of >10 min to blood product administration (once blood is called for).

    • Delay to administration of blood products to set up rapid infuser.

    • Greater than 1 L crystalloid bolus given in presumed hemorrhagic shock.

    • Failure to administer blood products or initiate vasopressors with ongoing shock (SBP <90).

    • Failure to activate massive transfusion protocol (if more than 2 units of blood products required).

    • Failure to control ongoing external bleeding.

    • Failure to identify/treat worsening hemodynamics or level of consciousness.

    • Failure to administer TXA in presumed hemorrhagic shock and injury <3 hours.

    • Failure to give platelets or fresh frozen plasma if >6 units of blood product given in trauma bay (ie, only pRBC given).

    • Primary resuscitative line is subdiaphragmatic (ie, femoral line, tibial IO) in patients with positive FAST or open book pelvis

    EMS handover
    • Failure or delay to activate trauma team.

    • Inaccurate or incomplete medical history report.

    • Team member(s) absent for EMS handover.

    • Patient assessment begins before EMS handover in stable patients.

    Management of injuries
    • Medication error.

    • Failure to treat hypothermia.

    • Failure to apply or incorrect application of pelvic binder in the setting of open book pelvic fracture.

    • Failure to offer effective analgesia/sedation to patients.

    • Failure to reduce fracture/dislocation in setting of pulseless limb.

    • Failure to provide patients with unique hospital ID or bracelet within 5 min of arrival.

    • Failure to administer hypertonic saline or mannitol in setting or presumed head injury with lateralizing signs or unilateral pupil deficit.

    Assessment of injuries
    • Failure to maintain cervical spine precautions (if indicated).

    • Failure to get X-rays before departure from trauma bay (if indicated).

    • Failure to complete primary survey before departure from trauma bay.

    • X-ray misinterpreted.

    • FAST misinterpreted.

    • Incomplete exposure of patients.

    • Failure to calculate GCS.

    • Failure to measure temperature.

    • Failure to assess circulation and function in injured limbs.

    Disposition
    • Delay more than 15 min waiting for CT.

    • Delay more than 15 min waiting for OR (if emergent OR).

    • Transfer to CT scan with hemodynamically unstable patients.

    Procedure related
    • Technical errors.

    • Equipment failure/missing.

    • Failure to perform an indicated resuscitative procedure.

    • Iatrogenic injury during procedure.

    • Knowledge deficits concerning equipment location.

    • Performing FAST examination interferes with ability to obtain initial intravenous access.

    • Bodily fluid exposure or needlestick injury to healthcare team member.

    Team communications and dynamics
    • Unclear responsibility and roles.

    • Patient care activities delayed or not completed due to task overload/competing priorities.

    • Team member unavailable.

    • Concurrent conversations preventing team leader communication.

    • Ineffective team leadership/unclear authority of team leader.

    • Failure to use closed-loop communication.

    • Clinical team members distracted by non-clinical-related tasks (ie, answering phone).

    • Inadequate personal protective equipment.

    • Trauma team leader leaves position to participate in patient care without delegating interim leader.

    Patient monitoring and access
    • Inadequate monitoring (ie, loss of telemetry, pulse oximetry for >3 min).

    • Failure of patient-monitoring equipment (ie, patient monitor, EtCO2, temperature probe).

    • Oxygen supply runs out.

    • Loss of all central/intravenous access.

    • Delay in assessment or treatment due to agitated or combative patients.

    • EMS, emergency medical services; EtCO2, end-tidal carbon dioxide; FAST, focused abdominal sonography in trauma; GCS, Glasgow Coma Scale; ID, identification; OR, operating room; pRBC, packed red blood cells; SBP, systolic blood pressure; TXA, tranexamic acid.

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Defining adverse events during trauma resuscitation: a modified RAND Delphi study
Brodie Nolan, Andrew Petrosoniak, Christopher M Hicks, Michael W Cripps, Ryan P Dumas
Trauma Surg Acute Care Open Oct 2021, 6 (1) e000805; DOI: 10.1136/tsaco-2021-000805

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Defining adverse events during trauma resuscitation: a modified RAND Delphi study
Brodie Nolan, Andrew Petrosoniak, Christopher M Hicks, Michael W Cripps, Ryan P Dumas
Trauma Surg Acute Care Open Oct 2021, 6 (1) e000805; DOI: 10.1136/tsaco-2021-000805
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Defining adverse events during trauma resuscitation: a modified RAND Delphi study
Brodie Nolan, Andrew Petrosoniak, Christopher M Hicks, Michael W Cripps, Ryan P Dumas
Trauma Surgery & Acute Care Open Oct 2021, 6 (1) e000805; DOI: 10.1136/tsaco-2021-000805
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