Teamwork errors in trauma resuscitation

Abstract

Human errors in trauma resuscitation can have cascading effects leading to poor patient outcomes. To determine the nature of teamwork errors, we conducted an observational study in a trauma center over a two-year period. While eventually successful in treating the patients, trauma teams had problems tracking and integrating information in a longitudinal trajectory, which resulted in inefficiencies and near-miss errors. As an initial step in system design to support trauma teams, we proposed a model of teamwork and a novel classification of team errors. Four types of team errors emerged from our analysis: communication errors, vigilance errors, interpretation errors, and management errors. Based on these findings, we identified key information structures to support team cognition and decision making. We believe that displaying these information structures will support distributed cognition of trauma teams. Our findings have broader applicability to other collaborative and dynamic work settings that are prone to human error. © 2012 ACM.