• H Trentzsch, S Imach, T Kohlmann, B Urban, L Lazarovici, and S Prückner.
• Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, Schillerstr. 53, 80336, München, Deutschland, Heiko.Trentzsch@med.uni-muenchen.de.
• Unfallchirurg. 2015 Aug 1; 118 (8): 675-85.

BackgroundEvery year preventable adverse events endanger a considerable number of patients. Current guidelines of the Federal Joint Committee require clinical quality management to provide amongst others an independent clinical risk management and a critical incident reporting system (CIRS). Such guidelines increase the pressure to actively deal with errors, even in emergency medicine. Human error is considered to be the main cause of preventable adverse events in high-risk industries, such as aviation. This observation is gladly directly transferred to clinical medicine.ObjectivesThis study investigated where the true causes for preventable adverse events during the resuscitation of severely injured patients can be found.MethodsA non-systematic literature search of the PubMed database was performed.ResultsThe search identified three recent studies addressing these objectives that revealed human error as the most important cause of preventable adverse events during emergency room resuscitation (88-97%). Errors during resuscitation in the emergency room occur in approximately 10 %. It is striking that such data do not differ greatly from findings described in studies undertaken 20 years ago. One possible explanation might be that the systematic evaluation of medical errors in the emergency room is a weak spot and that too few lessons can be learnt from such incidents. Therefore, this article describes models of error development and outlines methods to collect data for root cause analysis and for clinical risk management. Thus, this review aims at a better understanding of how errors originate and to allow development of strategies to prevent errors from happening again.ConclusionHuman error is the most important cause of preventable adverse events during emergency room resuscitation. Presumably, errors occur unintentionally and as a result of situational misjudgment. As such errors have marked consequences on mortality and morbidity of severely injured patients, an extensive risk management is mandatory for the improvement of quality and safety. Appropriate methods to record errors in order to allow a correct root cause analysis according to well-established protocols is a basic prerequisite.

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