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.

  • 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.

  • 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.