Breaking the silence: communication failures are the leading errors identified in 10-years of trauma morbidity and mortality conferences.

BACKGROUND

Despite global efforts to reduce trauma-related morbidity and mortality, diagnostic and therapeutic errors occur due to the urgency and complexity of care. Trauma morbidity and mortality (Trauma M&M) conferences aim to identify and address such errors to improve clinical outcomes. While most existing data on Trauma M&M conferences originate from the US, insights from Western Europe remain scarce.

METHODS

This single-center, retrospective case series analyzed trauma patients discussed at the monthly Trauma M&M at a Swiss Level I trauma center over 10 years (2013–2022). Data were collected from Trauma M&M records and electronic medical charts, including demographics, injury characteristics, timelines, and documented errors. A novel error categorization system was developed, encompassing communication, skill/knowledge deficits, delays, missed injuries, and deviations from algorithms.

RESULTS

Out of 198 trauma cases reviewed, 189 with complete data were further analyzed. The median Injury Severity Score was 32 (IQR 25–43). Of these patients, 77% died within 90 days. A total of 130 potential errors were identified, with communication errors ( = 29) being the most frequent, followed by skill/knowledge deficits ( = 24) and procedural delays ( = 19). Communication errors often triggered subsequent errors, such as missed diagnoses, under-triage, and deviations from protocols. Discussions during the Trauma M&M led to the introduction or refinement of clinical algorithms, including updates to triage protocols.

CONCLUSION

Communication errors emerged as the leading cause of errors in trauma care, highlighting the need for focused communication training. The Trauma M&M serves as an essential platform for interdisciplinary collaboration, quality improvement, and education. Future research should explore the ripple effects of communication errors and evaluate targeted interventions to optimize trauma care systems.