Ryder Trauma Patient Safety Organization
Ryder Trauma Patient Safety Organization specializes in trauma error analysis and outcomes data
Kenneth Stahl, MD FACS
Ryder Trauma PSO
The risks trauma patients face, not from their injuries or their disease processes but from the health care system itself are unique because of the special circumstances of trauma surgery care. Although the exact magnitude of errors patient face in our healthcare system is not known for certain, the fact that errors in patient care occur and that some patients are seriously and sometimes fatally harmed is not in dispute. Preventable deaths due to human and system errors account for up to 10% of fatalities in patients with otherwise survivable injuries cared for at US trauma centers. These unintended deaths equate to as many as 15,000 lost lives per year in the United States or 2 lives lost/hour, 24 hours/ day, 365 days/year. This rate of death due to error in trauma patients is two to four times higher than deaths due to errors reported in the general hospital patient population. The three highest risk areas for commission of errors have been identified in the places trauma surgeons work and trauma care is delivered; in the operating room, the emergency department and intensive care units. The situations that are most conducive to producing errors are the very environments in which trauma victims present; unstable patients, fatigued operators, incomplete histories, time-critical decisions, concurrent tasks, involvement of many disciplines, complex teams, transportation of unstable patients and multiple hand-offs of patient management. As such, trauma care creates a “perfect storm for medical errors”. As certified trauma centers we need to study these errors so that these events are better understood. The Ryder Trauma Center PSO has been established to collect incident, near miss and error data on this very special set of patients who have such a high risk of unintended adverse outcomes. Please join us in our efforts eliminate this risk to our patients.