Reducing Missed Injuries at a Level II Trauma Center

Easily missed pathologies of the musculoskeletal system in the emergency radiology setting

The musculoskeletal region is the main area in terms of easily missed pathologies in the emergency radiology setting, because the majority of diagnoses missed in the emergency setting are fractures.A review of the literature was performed by searching the PubMed and ScienceDirect databases, using the keywords ('missed injuries' or 'missed fractures') and ('emergency radiology' or 'emergency room') and ('musculoskeletal' or 'bone' or 'skeleton') for the title and abstract query. The inclusion criteria were scientific papers presented in the English and German languages. Among the 347 relevant hits between 1980 and 2024 as identified by the author of this review article, there were 114 relevant articles from the years between 2018 and 2024. Based on this literature search and the author's personal experience, this study presents useful information for reducing the number of missed pathologies in the musculoskeletal system in the emergency radiology setting.Predominant factors that make up the majority of missed fractures are 'subtle but still visible fractures' and 'radiographically imperceptible fractures'. Radiologists are able to minimize the factors contributing to fractures being missed. For example, implementing a 'four-eyes principle', i.e., two readers read the radiographs, would help to overcome the missing of 'subtle but still visible fractures' and the additional use of cross-sectional imaging would help to overcome the missing of 'radiographically imperceptible fractures'. Knowledge of what is commonly missed and evaluation of high-risk areas with utmost care also increase the diagnostic performance of radiologists. · Radiological imaging in an emergency setting increases the likelihood of radiological diagnostic errors, such as missing musculoskeletal pathologies.. · The majority of diagnoses missed in the emergency setting are fractures.. · To lessen the number of easily missed pathologies in the musculoskeletal system in the emergency radiology setting, a systematic approach is necessary.. · Adequate training of radiologists in emergency radiology and close collaboration with clinical partners are important measures to decrease the number of missed musculoskeletal injuries.. · Weber MA. Easily missed pathologies of the musculoskeletal system in the emergency radiology setting. Fortschr Röntgenstr 2024; DOI 10.1055/a-2369-8330.

Tertiary Trauma Survey on Emergency Department Observational Units: A Systematic Literature Review

In today's competitive world with a fast-paced lifestyle, trauma is on the rise and is globally recognized as the leading cause of mortality, morbidity, and disability. Despite the development of major trauma centers and the introduction of advanced trauma training courses and management guidelines, there remains a substantial risk of missed or delayed diagnosis of injuries with potentially life-changing physical, emotional, and financial implications. The proportion of such incidents is potentially higher in busy emergency departments and developing countries with fewer dedicated major trauma centers or where focused emergency and trauma training and skills development is still in its infancy. In the last decade, tertiary trauma surveys have been recognized as an important re-assessment protocol in reducing such missed injuries or delayed diagnoses in patients involved in major trauma. This naturally leads to the presumption that tertiary trauma surveys could also play an important role in observational medicine. This also brings into question whether a standardized tertiary trauma survey of major trauma patients on emergency observation units could reduce missed injuries, especially in low-income countries with fewer resources and trauma expertise. Thus, the purpose of this systematic literature review is to explore the potential role of tertiary trauma survey as a tool to reducing missed or delayed diagnosis in the emergency observation units and its applicability and feasibility in less-developed healthcare systems and in low- and middle-income countries. A broad-based systematic literature review was conducted to include electronic databases, grey literature, reference lists, and bibliographies using the keywords: tertiary trauma survey, major trauma, observational medicine, emergency observation units, clinical decision unit, adult, missed injuries, and delayed diagnosis. Over 19,000 citations were identified on initial search. Following a review of abstracts, application of inclusion and exclusion criteria, and review of the full article, 19 publications were finally selected for the purpose of this systematic literature review. Current evidence shows a general trend that tertiary trauma surveys performed 24 hours after admission play an important role in identifying injuries missed at the time of initial primary and secondary survey, and its implementation in observational medicine could prove beneficial, especially in resource-depleted healthcare systems.

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center

BACKGROUND

To investigate the incidence of osseous wrist and hand injuries on whole-body computed tomographies (WBCT) at an urban maximum-care trauma center, to report the number of missed cases in primary radiology reports, and to develop an algorithm for improved detection of these injuries.

METHODS

Retrospective analysis reviewing all WBCT for a period of 8 months for osseous wrist and hand injuries. (1) Reconstruction of hands/wrists in three planes (thickness 1-2 mm) and analysis by a blinded musculoskeletal radiologist. (2) Scanning of primary radiology reports and comparison to the re-evaluation. (3) Calculation of the diagnostic accuracy of WBCT during primary reporting. (4) Search for factors potentially influencing the incidence (trauma mechanism, associated injuries, Glasgow Coma Scale, artifacts). (5) Development of an algorithm to improve the detection rate.

RESULTS

Five hundred six WBCT were included between 01/2020 and 08/2020. 59 (11.7%) WBCT showed 92 osseous wrist or hand injuries. Distal intra-articular radius fractures occurred most frequently (n = 24, 26.1%); 22 patients (37.3%) showed multiple injuries. The sensitivity of WBCT in the detection of wrist and hand fractures during primary evaluation was low with 4 positive cases identified correctly (6.8%; 95% CI 1.9 to 16.5), while the specificity was 100% (95% CI 99.2 to 100.0). Forty-three cases (72.9%) were detected on additional imaging after clinical reassessment. Twelve injuries remained undetected (20.3%). Motorcycle accidents were more common in positive cases (22.0% vs. 10.1%, p = 0.006). 98% of positive cases showed additional fractures of the upper and/or lower extremities, whereas 37% of the patients without osseous wrist and hand injuries suffered such fractures (p < 0.001). The remaining investigated factors did not seem to influence the occurrence.

CONCLUSION

Osseous wrist and hand injuries are present in 11.7% on WBCT after polytrauma. 93.2% of injuries were missed primarily, resulting in a very low sensitivity of WBCT during primary reporting. Motorcycle accidents might predispose for these injuries, and they often cause additional fractures of the extremities. Clinical re-evaluation of patients and secondary re-evaluation of WBCT with preparation of dedicated multiplanar reformations are essential in polytrauma cases to detect osseous injuries of wrist and hand reliably.

TRIAL REGISTRATION

The study was registered prospectively on November 17th, 2020, at the German register for clinical trials (DRKS-ID: DRKS00023589 ).

Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative

BACKGROUND

Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS.

METHODS

Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests.

RESULTS

Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009).

CONCLUSION

Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals.

LEVEL OF EVIDENCE

Care management, Level IV.

The Impact of the Tertiary Survey in an Established Trauma Program

INTRODUCTION

The trauma tertiary survey (TTS) was first described in 1990 and is recognized as an essential practice in trauma care. The TTS remains effective in detecting secondary injuries in the modern era.

METHODS

Trauma patients discharged between August 1, 2016, and December 31, 2016, were identified in our trauma registry. Collected data include TTS completion rates, detection of injuries, type of provider, and timing. TTS documentation was qualitatively evaluated.

RESULTS

Out of 407 patients, 264 patients (65%) received a TTS. Injury detection rate was 1.1.%. Average time to TTS was 41 hours. TTS were completed by resident physicians (46%) and advanced practice providers (APPs; 46%). TTS documentation was more complete for APPs than for resident physicians.

CONCLUSION

TTS remains an integral component of modern trauma care. Ongoing education on the significance of TTS and the importance of thorough documentation is essential. Provision of real-time feedback to providers is also critical for improving current practices.

Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®

PURPOSE

Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®.

METHODS

In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU).

RESULTS

A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries. The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU.

CONCLUSION

In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.

Detection of fractures of hand and forearm in whole-body CT for suspected polytrauma in intubated patients

Background

The aim of this study was to evaluate the potential of whole-body CT for diagnosis of hand and forearm fractures in intubated patients with suspected polytrauma.

Methods

We performed a retrospective analysis on data collected from two trauma centres in Germany, including demographics, ISS, clinical symptoms, depiction in whole-body CT, and time to diagnosis.

Results

Out of 426 patients included in the study, 66 (15.5%) suffered a hand or forearm fracture. The total number of fractures was 132, the whole-body CT report mentioned 98 (74.2%). 16 (12,1%) fractures of 12 patients were diagnosed later than 24 h after admission. Late diagnoses of fractures of the hand occurred more often if the hand was not fully included in the CT scan field. The sensitivity of whole-body CT for cases with fractures of hand and/or forearm with full inclusion of the corresponding area in the scan field was 80.2%.

Conclusions

This study shows that whole-body CT is a valuable diagnostic tool for hand fractures in polytrauma patients. Hands should be evaluated regardless of clinical presentation in intubated patients after suspected polytrauma if they are included in the whole-body CT.

Diagnostic error in the emergency department: learning from national patient safety incident report analysis

BACKGROUND

Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.

METHODS

A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.

RESULTS

There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols.

CONCLUSIONS

Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Strategies to reduce diagnostic errors: a systematic review

Background

To evaluate the effectiveness of audit and communication strategies to reduce diagnostic errors made by clinicians.

Methods

MEDLINE complete, CINHAL complete, EMBASE, PSNet and Google Advanced. Electronic and manual search of articles on audit systems and communication strategies or interventions, searched for papers published between January 1990 and April 2017. We included studies with interventions implemented by clinicians in a clinical environment with real patients.

Results

A total of 2431 articles were screened of which 26 studies met inclusion criteria. Data extraction was conducted by two groups, each group comprising two independent reviewers. Articles were classified by communication (6) or audit strategies (20) to reduce diagnostic error in clinical settings. The most common interventions were delivered as technology-based systems n = 16 (62%) and within an acute care setting n = 15 (57%). Nine studies reported randomised controlled trials. Three RCT studies on communication interventions and 3 RCTs on audit strategies found the interventions to be effective in reducing diagnostic errors.

Conclusion

Despite numerous studies on interventions targeting diagnostic errors, our analyses revealed limited evidence on interventions being practically used in clinical settings and a bias of studies originating from the US (n = 19, 73% of included studies). There is some evidence that trigger algorithms, including computer based and alert systems, may reduce delayed diagnosis and improve diagnostic accuracy. In trauma settings, strategies such as additional patient review (e.g. trauma teams) reduced missed diagnosis and in radiology departments review strategies such as team meetings and error documentation may reduce diagnostic error rates over time.

Trial registration

The systematic review was registered in the PROSPERO database under registration number CRD42017067056.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0901-1) contains supplementary material, which is available to authorized users.

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients

PURPOSE

Missed injuries are reported in 1.3-65% of all admitted trauma patients. The severely injured patient that needs a higher level of care which requires an inter-hospital transfer has an increased risk for missed injuries. The aim of this study was to establish the incidence and clinical relevance of missed injuries in severely injured patients who require inter-hospital transfer to a level 1 trauma center.

METHODS

All patients with an Injury Severity Score (ISS) ≥ 16 transferred to the University Medical Center Groningen (UMCG) between January 2010 and July 2015 were included. Data were obtained from a prospective trauma database and supplemented with information from the patient records. A delayed diagnosis was defined as any injury detected within the first 24 h after the initial trauma, with or without a tertiary survey. Missed diagnoses were defined as any injury diagnosed after 24 h following trauma.

RESULTS

Two hundred and fifty-one trauma patients were included. A total of 88 patients (35%) were found to have ≥ 1 new diagnoses with 65 (26%) patients that had 1 or more delayed diagnoses and 23 (9.2%) patients had 1 or more missed diagnoses (detected > 24 h after injury) after transfer to our hospital. For 47 of the 88 patients (53%), the new diagnoses required a change of management. The Glasgow Coma Scale (GCS) was the only statistically significant risk factor for a new diagnosis upon transfer.

CONCLUSIONS

Inter-hospital transfer of severely injured patients increases the risk of a delayed detection of injuries. We found that 35% of all transferred patients with an ISS ≥ 16 have at least new diagnoses, with over half of these diagnoses requiring a change of management. Given these findings, clinicians should maintain a high index of suspicion when receiving a transferred severely injured trauma patient.

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial

Background

Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge.

Methods/Design

We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality.

Discussion

The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders.

Trial registration

ANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0733-y) contains supplementary material, which is available to authorized users.

A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey

Objective

This study prospectively evaluated in-hospital and postdischarge missed injury rates in admitted trauma patients, before and after the formalisation of a trauma tertiary survey (TTS) procedure.

Methods

Prospective before-and-after cohort study. TTS were formalised in a single regional level II trauma hospital in November 2009. All multitrauma patients admitted between March–October 2009 (preformalisation of TTS) and December 2009–September 2010 (post-) were assessed for missed injury, classified into three types: Type I, in-hospital, (injury missed at initial assessment, detected within 24 h); Type II, in-hospital (detected in hospital after 24 h, missed at initial assessment and by TTS); Type III, postdischarge (detected after hospital discharge). Secondary outcome measures included TTS performance rates and functional outcomes at 1 and 6 months.

Results

A total of 487 trauma patients were included (pre-: n = 235; post-: n = 252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8 vs. 4.8 %, P = 0.61), as were postdischarge missed injury rates (Type III) at 1 month (13.7 vs. 11.5 %, P = 0.43), and 6 months (3.8 vs. 3.3 %, P = 0.84) after discharge. TTS performance was substantially higher in the post-group (27 vs. 42 %, P < 0.001). Functional outcomes for both cohorts were similar at 1 and 6 months follow-up.

Conclusions

This is the first study to evaluate missed injury rates after hospital discharge and demonstrated cumulative missed injury rates >15 %. Some of these injuries were clinically relevant. Although TTS performance was significantly improved by formalising the process (from 27 to 42 %), this did not decrease missed injury rates.

Surgeon commitment to trauma care decreases missed injuries

STUDY OBJECTIVE

Missed injuries sustain an important issue concerning patient safety and quality of care. The purpose of this study is to examine the effect of surgeon commitment to trauma care on missed injuries. We hypothesised that surgeons committed to the trauma service has less missed injuries than surgeons not committed to the trauma service would have.

METHODS

By retrospective analysis of 976 adult patients admitted to the trauma intensive care unit (ICU) at an urban, university-based trauma centre. Missed injuries were compared between two groups; in group 1 the patients were evaluated and treated by the surgeons who were committed to the trauma service and in group 2 the patients were evaluated and treated by surgeons practicing mainly in other specialties.

RESULTS

Patients had significantly lower rates of missed major or life-threatening injuries when treated by group 1 surgeons. Logistic regression model revealed significant factors associated with missed major or life-threatening injuries including ISS and groups in which patients were treated by different group surgeons.

CONCLUSIONS

Physicians will perform better when they are trained and interested in a specific area than those not trained, or even not having any particular interest in that specific area. Surgeons committed to the trauma service had less missed injuries in severely injured patients, and it is vital to improve patient safety and quality of care for trauma patients. Staff training and education for assessing severely injured patients and creating an open culture with detection and reduction of the potential for error are important and effective strategies in decreasing missed injuries and improving patient safety.

System-related factors contributing to diagnostic errors

Several studies in primary care, internal medicine, and emergency departments show that rates of errors in test requests and result interpretations are unacceptably high and translate into missed, delayed, or erroneous diagnoses. Ineffective follow-up of diagnostic test results could lead to patient harm if appropriate therapeutic interventions are not delivered in a timely manner. The frequency of system-related factors that contribute directly to diagnostic errors depends on the types and sources of errors involved. Recent studies reveal that the errors and patient harm in the diagnostic testing loop have occurred mainly at the pre- and post-analytic phases, which are directed primarily by clinicians who may have limited expertise in the rapidly expanding field of clinical pathology. These errors may include inappropriate test requests, failure/delay in receiving results, and erroneous interpretation and application of test results to patient care. Efforts to address system-related factors often focus on technical errors in laboratory testing or failures in delivery of intended treatment. System-improvement strategies related to diagnostic errors tend to focus on technical aspects of laboratory medicine or delivery of treatment after completion of the diagnostic process. System failures and cognitive errors, more often than not, coexist and together contribute to the incidents of errors in diagnostic process and in laboratory testing. The use of highly structured hand-off procedures and pre-planned follow-up for any diagnostic test could improve efficiency and reliability of the follow-up process. Many feedback pathways should be established so that providers can learn if or when a diagnosis is changed. Patients can participate in the effort to reduce diagnostic errors. Providers should educate their patients about diagnostic probabilities and uncertainties. The patient-safety strategies focusing on the interface between diagnostic system and therapeutic intervention are strategies that involve both processes to facilitate appropriate follow-up and structural changes, such as the use of electronic tracking systems and patient navigation programs.

Delayed diagnosis of hand injuries in polytrauma patients

Trauma patients are at high risk for delayed diagnosis of injuries, including those to the hand, with reports in the literature as high as 50%. As a result, patients may have prolonged disability and longer hospital stays with associated increased costs. Our objective was to elucidate risk factors for the delayed diagnosis of hand injuries. A review was performed from 2000 through 2009, assessing for age, sex, blood alcohol level, Glasgow Coma Score (GCS), Injury Severity Score (ISS), mechanism, injury type, length of stay, and timing of hand injury diagnosis. In this study, 36,568 patients were identified; 738 meeting criteria; 21.7% of patients had delayed diagnoses with 91.3% of patients diagnosed by the day after admission. Delayed diagnoses were more than 2 times higher for severely injured patients. Patients with delayed diagnoses had a lower GCS and a higher ISS and length of hospitalization. With a decreased GCS and elevated ISS, patients are at risk for delayed diagnoses of hand injuries. A focused tertiary survey is mandatory, particularly in patients with an altered mental status or with multiple injuries.

The effect of tertiary surveys on missed injuries in trauma: a systematic review

Background

Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes.

Methods

A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. ‘Missed injury’ was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale.

Results

Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01).

Conclusions

Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.

System-related interventions to reduce diagnostic errors: a narrative review

BACKGROUND

Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors.

METHODS

The authors conducted a comprehensive search using multiple search strategies. First, they performed a PubMed search to identify articles exclusively related to diagnostic error or delay published in English between 2000 and 2009. They then sought papers from references in the initial dataset, searches of additional databases, and subject matter experts. Articles were included if they formally evaluated an intervention to prevent or reduce diagnostic error; however, papers were also included if interventions were suggested and not tested to inform the state of the science on the subject. Interventions were characterised according to the step in the diagnostic process they targeted: patient-provider encounter; performance and interpretation of diagnostic tests; follow-up and tracking of diagnostic information; subspecialty and referral-related issues; and patient-specific care-seeking and adherence processes.

RESULTS

43 articles were identified for full review, of which six reported tested interventions and 37 contained suggestions for possible interventions. Empirical studies, although somewhat positive, were non-experimental or quasi-experimental and included a small number of clinicians or healthcare sites. Outcome measures in general were underdeveloped and varied markedly among studies, depending on the setting or step in the diagnostic process.

CONCLUSIONS

Despite a number of suggested interventions in the literature, few empirical studies in the past decade have tested interventions to reduce diagnostic errors. Advancing the science of diagnostic error prevention will require more robust study designs and rigorous definitions of diagnostic processes and outcomes to measure intervention effects.

Incidence rate and risk factors of missed injuries in major trauma patients

This study was designed to determine the incidence rate and risk factors of missed injuries in major trauma patients in the emergency department (ED). Hospital records of all 976 trauma patients visiting the ED and admitted to intensive care units (ICUs) of a medical center in Taiwan from 2006 to 2007 were reviewed. Missed injuries were defined as those not identified in the ED but recognized later in the ICUs. Clinically significant injuries were those with an Abbreviated Injury Scale of ≥ 2. In the 2-year period, there were 133 missed injuries in 118 patients in the ED, for a prevalence of 12.1%; 87 injuries were clinically significant in 78 patients, for a prevalence of 8.0%. The estimated incidence rate per 100 person-hours was 3.2 for missed injuries and 2.1 for clinically significant missed injuries. The most commonly involved body region of missed injuries was the head/neck, followed by the chest and extremities. Results of a Cox regression analysis showed that a younger age, more-severe injury, polytrauma, and the absence of soft-tissue injuries were significantly associated with missed injuries, while younger ages, more-severe injuries, and the presence of chest and pelvic injuries were also significantly associated with clinically significant missed injuries. In conclusion, a considerable number of injuries, particularly to the head/neck, may be undetected in the ED, while young people and patients with certain injury patterns such as severity levels, polytrauma, and the presence of a chest or pelvic injury are more likely to have missed injuries and/or clinically significant missed injuries.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.