Pitfalls and Traps in the Management of Major Trauma

Robert C. Mackersie, MD, FACS Department of Surgery at San Francisco General Hospital speaks on the Pitfalls and Traps in the Management of Major Trauma at the annual Southwest Trauma & Acute Care Symposium. A pitfall is a n unapparent source of trouble or danger; a hidden hazard potentially leading to errors and adverse outcomes. There are external, internal, and latent threats. He uses resuscitation to demonstrate the dynamics and failures. These include communication, inappropriate workload distribution, conflict resolution, and situational awareness. Classification of errors include taxonomy and cognitive theory. Additional stratification of errors for PI purposes includes classifying them as retrospective or prospective. Errors often observed in the trauma environment are false attribution, false negative prediction, and labeling. Trauma is a low-reliability, high-risk environment and human error is an inescapable component of a medical system of care.