Using Video Recording to Identify Management Errors in Pediatric ...

Using Video Recording to Identify Management Errors in Pediatric Trauma Resuscitation Ed Oakley, Sergio Stocker, Georg Staubli and Simon Young Pediatrics 2006;117;658-664 DOI: 10.1542/peds.2004-1803

This information is current as of August 22, 2006

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/117/3/658

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Using Video Recording to Identify Management Errors in Pediatric Trauma Resuscitation Ed Oakley, MBBS, FACEMa, Sergio Stocker, MDb, Georg Staubli, MDb, Simon Young, MBBS, FACEMa a

Department of Emergency Medicine, Royal Children’s Hospital, Melbourne, Australia; bChildren’s University Hospital, Zurich, Switzerland

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT OBJECTIVE. To determine the ability of video recording to identify management errors

in trauma resuscitation and to compare this method with medical record review. METHOD. The resuscitation of children who presented to the emergency department

of the Royal Children’s Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. RESULTS. Ninety resuscitations were video recorded and analyzed. An average of 5.9

errors per resuscitation was identified with this method (range: 1–12 errors). Twenty-five children (28%) had an injury severity score of ⬎11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement.

www.pediatrics.org/cgi/doi/10.1542/ peds.2004-1803 doi:10.1542/peds.2004-1803 Key Words video recording, trauma, resuscitation Abbreviations CCRTF—Consultative Committee on Road Traffic Fatalities ISS—injury severity score ED— emergency department RCH—Royal Children’s Hospital ATLS—Advanced Trauma Life Support Accepted for publication Jul 8, 2005 Address correspondence to Ed Oakley, MBBS, FACEM, Department of Emergency Medicine, Royal Children’s Hospital, Flemington Road, Parkville 3052, Australia. E-mail: ed.oakley@ rch.org.au PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2006 by the American Academy of Pediatrics

CONCLUSIONS. Video recording is more effective than medical record review in de-

tecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

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SSESSING TRAUMA RESUSCITATION management has always been an imprecise science. Most published works are retrospective reviews of the medical records of adult patients, with only a few studies using real-time video recording and fewer looking at the pediatric population. Studies from Australia1,2 and the United States3 identified errors in trauma management, including errors that contributed to death. All of these studies used retrospective medical record review and likely underestimated the size of the problem. The Consultative Committee on Road Traffic Fatalities (CCRTF) identified a minimum of 3 errors per resuscitation in its review.2 The CCRTF also noted that the majority of resuscitation errors occurred in the emergency department (ED).1 For some time, video recording has been used to evaluate patient management. Video recording has been shown to be a useful practical tool.4–8 It has the advantages of providing accurate times to interventions that are not hindered by poor documentation or the memory of those involved. The Royal Children’s Hospital (RCH) (Melbourne Australia) is a 240-bed tertiary pediatric hospital and the state’s only pediatric trauma service. There are ⬃1500 trauma admissions per year, of which ⬃150 are defined as major trauma, ie, meeting ⱖ1 of the following criteria: injury severity score (ISS)9 of ⬎15; abbreviated injury score9 of ⱖ2 in ⱖ2 ISS body regions (excluding external genitalia); admission to an ICU for ⬎24 hours; requiring mechanical ventilation; urgent surgery for treatment of intracranial, intrathoracic, or intraabdominal injury or for fixation of pelvic or spinal fractures; or death after injury; 210 are classified as serious injuries, ie, major trauma or ISS of ⬎11. Because this is the only pediatric trauma center for the state of Victoria, ⬃50% of the major trauma cases are transferred from other institutions. In our institution, there are 2 areas that receive trauma patients for resuscitation, the ED and the ICU. Children who arrive by helicopter and need urgent resuscitation or are intubated are examined and resuscitated in the ICU. Approximately 40% of all major trauma admissions are treated directly in the ICU. There are specific guidelines controlling the activation of the trauma team, and a response by all members is expected to be immediate. A decision was made to video record the trauma team resuscitating children in the ED, with the aims of (1) auditing the trauma team response, (2) investigating the ability of video recording to identify management errors made by the trauma team, and (3) determining whether video recording provided information that was not available in the medical record.

METHODS All children who presented to the ED of the RCH between February 19, 2001, and August 18, 2002, for whom the trauma team was activated were to be video recorded. The video camera is located on the ceiling of

the resuscitation room, and ED medical or nursing staff members started the video recording with a remote activation switch on the wall of the resuscitation rooms. Initially we also planned to video record trauma patients resuscitated in the ICU, but problems with locating the camera and storing the equipment forced this part of the project to be abandoned. The camera used is a ceiling-mounted, Panasonic WV-651, analog, combination video/audio camera. Each camera can be activated through a wall-mounted switch in the resuscitation room and has a remote control in an adjacent room for panning and zooming. Each camera is linked to a Panasonic AG-TL700 SVHS video recorder, which is also located in the adjacent room. Remote manipulation of the camera was used rarely in the study. Before commencement of the study, the errors to be assessed were defined and acceptable deviations from management were agreed on. Advanced Trauma Life Support (ATLS) guidelines for the resuscitation of seriously injured patients were used as the standard (eg, a delay to oxygen therapy of ⬎5 minutes was agreed as an error, and 1 intravenous cannula for a child who required fluid resuscitation or intubation or who had obvious injuries to ⱖ2 body regions was considered inadequate). Initially, the investigators reviewing the video recording did so together and agreement on interpretation of events was reached. All subsequent videotapes were reviewed by Dr Stocker or Dr Staubli, with 50 tapes also being reviewed by Dr Oakley. No tape was reviewed by a person involved in the resuscitation. Comments were added to explain omissions of care that were deemed reasonable for the individual patient. All videotapes were viewed within 2 weeks after the resuscitation and then erased. Data collected included personnel present and timing of their arrival; trauma team leadership and communication; management of the airway, breathing, and circulation; management of the spine; resuscitation undertaken and interventions performed at these stages; completeness of the secondary survey; and time to definitive care. The trauma service database was used to identify patients with an ISS of ⬎11. Medical records of these patients were reviewed to determine whether the history documented the resuscitation errors seen on the videotape and whether management was documented in the history that was not seen on the video recording. Patient outcomes were assessed by 2 surgeons who were blinded to the management errors identified. They gave a consensus opinion on whether the outcome was poor and whether this was unexpected on the basis of the injuries sustained. All results are presented in a descriptive format. Interrater reliability was determined with the 50 videotapes that were reviewed by 2 reviewers. The project was reviewed by the RCH Ethics in Human Research Committee and was approved as an auPEDIATRICS Volume 117, Number 3, March 2006

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diting tool. The RCH medicolegal office was consulted regarding privacy issues for staff members and patients and advised that, as an auditing tool, the project was exempt from existing privacy legislation. RESULTS Study Group A total of 105 trauma resuscitations were video recorded in the 18-month period of the study; 45 trauma resuscitations were not video recorded, 31 because of machine-related problems and 14 because of staff members not turning on the video recorder. Of the resuscitations that were video recorded, 15 tapes were excluded because of interference on the tapes, which made them unviewable. Therefore, 90 video recorded trauma resuscitations were reviewed. The view of the patient was adequate in all tapes reviewed. Figure 1 shows the standard view of the patient. The mean age of patients was 10.1 years (median: 9.5 years; range: 0.9 –17 years). The male/female ratio was 1.7:1. The median ISS of all patients was 5 (interquartile range: 4 –14; minimum: 1; maximum: 45). Four children arrived between midnight and 8 AM, 5 between 8 AM and noon, 41 between noon and 6 PM, and 40 between 6 PM and midnight. The ISS, age, and gender of the participants are compared with those of excluded patients in Table 1. Trauma team roles were clearly defined in 60% of resuscitations and, on these occasions, communication was good. All resuscitations without a clear team leader had poor communication and poor coordination of the resuscitation. The ED and ICU staff members were present at patient arrival in every instance, but the surgical team and neurosurgical team were delayed ⬎15 minutes after patient arrival in 45% and 77% of cases,

FIGURE 1 Still image of view of resuscitation from camera (video link).

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TABLE 1 Comparison of Subjects and Excluded Patients

Age, median (IQR), y Male/female ratio ISS, median (IQR)

Study Group (N ⫽ 90)

Excluded Group (N ⫽ 60)a

9.5 (5.2–13.9) 1.7:1 5 (4–14)

9.1 (4.8–12.5) 1.5:1 6 (4–14)

IQR indicates interquartile range. a Not videotaped: 45 cases; tape not viewable: 15 cases.

respectively. An adequate number of appropriately experienced personnel were present to instigate all necessary resuscitation at patient arrival. Errors Identified in Patient Assessment and Management A total of 532 errors of management were identified, with an average of 5.9 errors per resuscitation; 219 errors involved management of the airway and breathing, 124 errors involved management of the circulation, 32 errors were failures of spinal immobilization, and 157 errors occurred with the secondary survey. There was no resuscitation that was free of errors, with a range of errors of 1 to 12. Management errors are described in detail in Table 2. The most common error in the management of the airway and breathing was a delay in applying oxygen of ⬎5 minutes after arrival. All children were expected to have oxygen applied as part of the primary survey irrespective of their presenting condition. For 19 children (21%), no errors were detected in the management of the airway and breathing. There were 10 urgent intubations required, with no delay to airway control identified. Five children required urgent thoracostomy, with no delay in identifying this need or performing the procedure. The only detected error in cervical spine management was not providing head stabilization while transferring the patient. No patients had the cervical spine cleared before arrival or before the video was started. The Victorian ambulance service treats all potential major trauma with a cervical collar. In management of the circulation, 36 (40%) children had 1 intravenous cannula, 32 (36%) had 2 cannulas, and 22 (24%) had no intravenous access. Not all of the children were seriously injured, and the reviewing researcher recorded that the level of venous access was inappropriate in 18 cases (20%). To be regarded as an error, a child with 1 or no intravenous cannula had to need an intravenous fluid bolus, to have expected injury to ⱖ2 body regions on the visual examination, or to need intubation. The size of the cannula could rarely be determined on the videotape. Thirty-seven patients (40%) received a fluid bolus. Volumes of fluid delivered were difficult to assess, and vital signs were often not visible on the videotape; therefore, the need for and adequacy of fluid resuscitation

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TABLE 2 Management Errors Among All Patients (N ⴝ 90) Errors Identified

n (%)

Description

Airway and breathing Delay in oxygen therapy

60 (67)

Chest not auscultated Oxygen saturation not measured Neck not adequately examined Cervical spine No head stabilization on transfer Circulation Inappropriate intravenous access

40 (44) 33 (37) 71 (79)

All patients to have oxygen as part of primary survey; allowed 5 min to institute Allowed 5 min to institute Allowed 5 min to institute No inspection with or without palpation without collar on

18 (20)

All patients had well fitted collar

18 (20)

Pulse not assessed Central capillary refill not assessed Blood pressure not measured Fluid bolus not warmed Disability Pupils Posture Secondary survey Perineum not examined Mouth not examined Head not examined Back not examined

37 (41) 59 (66) 28 (31) 33 of 37 (89)

One intravenous cannula for patient requiring fluid bolus, with injuries to ⱖ2 body regions or requiring intubation, was inappropriate; cannula size not able to be assessed All patients had ECG monitoring All patients had either blood pressure or capillary refill measured 37 patients had fluid bolus and only 4 had warmed fluids

Ears not examined Abdomen not examined Chest not examined Communication No team leader Poor team function

22 (25) 22 (25) 41 (45) 41 (45) 13 (15) 13 (15)

16 (18) 2 (2) 3 (3) 38 (40) 38 (40)

Same 22 patients had these missed

All had adequate time to have back examined; patients rushed to CT suite or operating room were not required to have back examined Not palpated Visual inspection and palpation not done Lack of adequate team leadership was always associated with poor team function; a team leader was deemed present if 1 team member was overseeing patient management (without hands-on involvement) and was focus of communication

ECG indicates electrocardiographic; CT, computed tomography.

were difficult to determine (Fig 1). Circulation assessment was adequate for 31 patients (35%). The secondary survey was incomplete for 71 patients (79%) before the patient left the resuscitation room. The abdomen and chest were not examined for only 2 and 3 patients, respectively. Errors Among Seriously Injured Children (ISS of >11) Children with an ISS of ⬎11 represented 28% of our patients (25 patients). There were a total of 54 errors made in this group, an average of 2.16 errors per patient. Fifteen errors for 5 children involved management of the airway and breathing, 23 errors for 12 children involved management of the circulation, and 12 children received an inadequate secondary survey. These errors are described in detail in Table 3. Errors Detected Through Medical Record Review A detailed medical record review was undertaken for these more seriously injured children. Only 10 (20%) of

the 54 errors detected on the video recording were detected in the medical record review. The medical record indicated an examination that was not detected on the video recording in 6 instances, and 8 additional errors were identified in the history review; these consisted of 3 drug dosing errors, 3 fluid dosing errors, and 2 vital sign abnormalities that should have directed fluid resuscitation that was not undertaken (Table 4). The drugs and type of fluid administered and the doses given could be understood much more clearly from the history. The vital signs and changes in the patient’s condition over time were better defined, and a better understanding of the reasons for some of the interventions made was possible Patient Outcomes There were 10 patients with poor outcomes, ie, 4 deaths and 6 children who remained with significant disability. None of these outcomes was judged to be unexpected from the severity of the injury (Table 5). Five patients PEDIATRICS Volume 117, Number 3, March 2006

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TABLE 3 Errors Among Seriously Injured Patients (ISS >11; N ⴝ 25) Errors Identified Airway and breathing Delay in oxygen therapy Chest not auscultated Oxygen saturation not measured Neck not adequately examined Cervical spine Circulation Inappropriate intravenous access Pulse not assessed Central capillary refill not assessed Blood pressure not measured Disability Secondary survey Perineum not examined Mouth not examined Head not examined Back not examined Ears not examined

n (%)

Description

3 (12) 3 (12) 5 (20) 4 (16) 0 (0)

1 of these had no oxygen therapy because was too agitated

6 (24) 6 (24) 3 (12) 8 (32) 0 (0)

6 patients who required fluid bolus

12 (48) 3 (12) 5 (20) 3 (12) 4 (16)

TABLE 4 Errors Found in History Review and Not Seen on Videotapes (n ⴝ 8) Drug dosing errors (n ⫽ 3) Underdosing of flucloxacillin by 50% Underdosing of suxamethonium for head-injured child; intubated without difficulty (dose given: 0.5 mg/kg) Underdosing of penicillin by 40% Fluid errors (n ⫽ 3) Fluid bolus of 5 mL/kg Fluid bolus with 4% dextrose in 0.18% saline Fluid bolus of 7 mL/kg Lack of intervention (n ⫽ 2) Persistent change in blood pressure (from mean of 70 mm Hg to mean of 50 mm Hg) for 10-y-old child with only 5 mL/kg fluid bolus 14-y-old child with persistent tachycardia (heart rate: ⬎130 beats per min) for 30 min before fluid bolus given

were documented to have unexpected complications. Two of these were related to surgery (1 wound infection and 1 complication of external fixation), 1 was related to drug error (a patient who was allergic to penicillin received flucloxacillin after admission and developed a rash), and 2 were infections related to intravenous access. Interrater Agreement In the 50 tapes reviewed by 2 reviewers, there was 93% agreement in the allocation of management errors. The most significant disagreement was seen in the adequacy of neck examination (80% agreement) and whether the pulse was assessed (83% agreement). There was 100% agreement regarding the adequacy of intravenous access, delay in oxygen therapy, and saturations not recorded. The ␬ score for the interrater agreement was 0.83 (95% confidence interval: 0.7– 0.96). 662

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No inspection or palpation of neck

Had no capillary refill or blood pressure assessments

Included 1 patient with displaced pelvic fracture

Including 3 patients with moderate/severe head injury

DISCUSSION This research indicates that video recording is an effective method for detecting management errors in trauma reception. It also suggests that, in a more seriously injured patient group, video recording is more efficient than traditional medical record review in detecting most errors. This is not an unexpected finding, given the complex nature of trauma resuscitation and a natural focus on treating the patient rather than recording events. The reality is that many notes in the medical record are written well after the events and are influenced heavily by the author’s memory and perception of what happened. We have demonstrated that video recording, if used alone, has definite limitations. It was difficult to assess accurately the clinical state of the patient on the video recording without contemporaneous vital signs. This restricted the ability of the reviewers to judge the timeliness and effectiveness of interventions. Combining video recording with a direct stream of vital signs from a central monitoring system that allowed continuous recording would overcome this problem. Video recording gave only limited information on drug doses and fluid volumes. These were recorded more accurately in the medical record. Medical record review still needs to be performed to check these aspects of resuscitation. The high rate of errors detected in our study is partly attributable to the effectiveness of video recording and partly attributable to the strict definition of what constituted an error. Deviations from ATLS guidelines were recorded as errors and reasonable timelines were agreed on to ensure timely care irrespective of the severity of the child’s injuries. It is possible that experienced clinicians would not adhere to all of the ATLS guidelines for

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TABLE 5 Details of Errors Among Patients With Poor Outcomes (n ⴝ 10) Patients Deaths (n ⫽ 4) 12-y-old pedestrian struck by car; severe open head injury and multiple fractures of the pelvis; recurrent hypotension and severe bradycardia; died in operating room 17-mo-old child backed over in driveway; severe head injury and atlanto-occipital dislocation; died in ICU 4-y-old child pulled television onto himself; severe head and chest injuries; died in ED 9-y-old child fell down cliff; prolonged extrication time; severe head injury; died in ICU Morbidity (n ⫽ 6) 2-y-old pedestrian hit by car; severe head injury; discharged with severe global neurologic dysfunction 6-y-old child in motor vehicle accident; abdominal and lower limb injuries; discharged with inability to use right leg 14-y-old child in push bike versus car accident; severe head injury; discharged to rehabilitation with motor and speech deficits 10-y-old child with severe isolated head injury; intubated in ambulance; no resuscitation required in ED; discharged with significant memory impairment 3-y-old child fell from balcony; severe head injury, facial fractures, and femur fracture; discharged with blindness in 1 eye and facial deformity 13-y-old child fell from cliff; spinal fracture and incomplete paraplegia (T10); discharged with T10 incomplete paraplegia, unable to walk

all patients that we video recorded, especially those with more minor trauma. It could be questioned whether ATLS guidelines were appropriate for the 37 patients with an ISS of ⬍5. However, because they had already met the criteria for trauma team activation, we thought this was reasonable, given the difficulties in ascertaining the degree of injury initially. Indeed, far fewer errors were detected in the more seriously injured group, which reassured us that, on the whole, this group received appropriate care. Our results indicate that management errors in pediatric trauma resuscitation are frequent (an average of 5.9 errors per patient resuscitation). The errors made involved basic resuscitation principles. There were no errors of intubation or other invasive interventions. The error rate was greater than that found by the CCRTF, which documented 3 errors per resuscitation in the ED.2 Like most other reviews of resuscitation,1–3 that review was a retrospective review of hospital and ambulance records and would have missed some errors because of lack of documentation. Indeed, our history review showed that it would have missed up to 80% of simple management errors. The review of timing of the arrival of team members provided useful information. Historically, the trauma team leader in our institution was the surgical registrar. After we identified that they were not present at the

Management Errors Perineum not examined

No blood pressure or capillary refill measured; mouth not examined Perineum and ears not examined Ears not examined; pulse not assessed

Neck not inspected or palpated adequately; perineum and mouth not examined Blood pressure not measured; delay in oxygen therapy Back not examined

Inadequate intravenous access; blood pressure not measured Inadequate intravenous access; back not examined Head and neck not examined

beginning of resuscitation in ⬃50% of cases and that this created confusion among the team, the team leader role was moved to the emergency physician. To address the pattern and frequency of errors, we instituted 12 hours of teaching, focusing on basic principles of trauma management, which all members of the trauma team receive when beginning at the hospital. There is a growing body of evidence that video recording can be a useful tool in resuscitation evaluation.4–8 Those studies compared trauma resuscitation to ATLS guidelines and neonatal resuscitation to existing guidelines. They documented errors that occurred, but only the neonatal review examined the frequency of errors. Unlike Carbine et al,6 who demonstrated a 48% perfect neonatal resuscitation rate, we were unable to demonstrate a single resuscitation that was devoid of error. Some feedback on the management and communication errors was given to the trauma team. However, there was no difference in behavior or errors at the beginning versus the end of the study. The patients in this study who had poor outcomes experienced a number of management errors. Some of these errors might have contributed to slow or delayed resuscitation, but none was seen to be the sole cause of the poor outcome This differs from the findings of the CCRTF, which identified an average of 1 error per resuscitation that contributed to death.2 The CCRTF studPEDIATRICS Volume 117, Number 3, March 2006

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ies only road traffic fatalities, and our population was not as seriously injured. Patient and staff privacy is an issue that is often put forward as an impediment to video recording.7,10 This study was reviewed by our institutional ethics committee and deemed to be a standard auditing tool. No patient or parental consent was deemed necessary; indeed, it was thought to be impractical. The staff members were educated about the role of the video recording and the auditing process. All staff members agreed to the video recording, and no staff members expressed complaints. Patient privacy issues were investigated with the hospital’s medicolegal office, and it was thought that using videotaping as a standard auditing tool exempted the procedure from privacy legislation and it could be used in an ongoing process to improve patient management. The cost of video recorder installation and the time taken to review the videotapes (on average, 40 minutes) means that not all departments would have the resources necessary to use this tool. The time taken to review the histories (on average, 1 hour) had a significant impact on our ability to continue to audit all trauma resuscitations. We plan to develop an electronic resuscitation record and video recording that can be viewed concurrently, to limit the time taken to audit trauma care. The number of children in this study limits the ability to identify clearly the relationship between adverse events and management. We documented a number of significant omissions in practice that potentially could contribute to poor outcomes and might have contributed to the outcomes of some of the patients in this study, but the number of poor outcomes was too small to determine this. Although management errors have been shown to be relatively frequent events,2,11,12 the proportion leading to adverse events has been shown to be ⬃1%.11,12 Therefore, many hundreds of patients would need to be studied to identify the errors that are associated with adverse events. Furthermore, the identified difficulties in viewing the videotapes mean that some management errors might have been missed and some management appropriate for the individual child might have been considered an error. One half of the videotapes were reviewed by 1 reviewer. Although the interrater agreement was high, there is a potential for bias. We were unable to videotape all trauma resuscitations at our hospital, and excluding patients who were resuscitated in the ICU potentially excluded a more seriously injured cohort.

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CONCLUSIONS Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Video recording should be an integral part of overall management assessment and should be accompanied by review of the resuscitation history. Efforts to simplify the process by using new technologies, such as an electronic resuscitation record with continuous electronic vital sign recording, should be explored.

ACKNOWLEDGMENT The Victorian Trauma Foundation provided a research grant to fund the project.

REFERENCES 1. McDermott FT, Cordner SM. Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria, Australia. J Trauma. 1997;43: 831– 839 2. Cooper DJ, McDermott FT, Cordner SM, Tremayne AB. Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in Victoria, Australia: Consultative Committee on Road Traffic Fatalities in Victoria. J Trauma. 1998;45:772–779 3. Esposito TJ, Sanddal ND, Dean JM, Hansen JD, Reynolds SA, Battan K. Analysis of preventable pediatric trauma deaths and inappropriate trauma team care in Montana. J Trauma. 1999; 47:243–253 4. Noland J, Treadwell D. Video evaluation of pediatric trauma codes. Int J Trauma Nurs. 1996;2:42– 48 5. Santora TA, Trooskin SZ, Blank CA, Clarke JR, Schinco MA. Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med. 1996;14:564 –569 6. Carbine DN, Finer NN, Knodel E, Rich W. Video recording as a means of evaluating neonatal resuscitation performance. Pediatrics. 2000;106:654 – 658 7. Blank-Reid CA, Kaplan LJ. Video recording trauma resuscitations: a guide to system set-up, personnel concerns, and legal issues. J Trauma Nurs. 1996;3:9 –12 8. Ritchie P, Cameron P. An evaluation of trauma team leader performance by video recording. Aust NZ J Surg. 1999;69: 183–186 9. Linn S. The Injury Severity Score: importance and uses. Ann Epidemiol. 1995;5:440 – 446 10. Michaelson M, Levi L. Videotaping in the admitting area: a most useful tool for quality improvement of the trauma care. Eur J Emerg Med. 1997;4:94 –96 11. Fordyce J, Blank FS, Pekow P, et al. Errors in a busy emergency department. Ann Emerg Med. 2003;42:324 –333 12. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678 –1686

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Using Video Recording to Identify Management Errors in Pediatric Trauma Resuscitation Ed Oakley, Sergio Stocker, Georg Staubli and Simon Young Pediatrics 2006;117;658-664 DOI: 10.1542/peds.2004-1803 This information is current as of August 22, 2006 Updated Information & Services

including high-resolution figures, can be found at: http://www.pediatrics.org/cgi/content/full/117/3/658

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