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Table 2 Components of the major trauma case peer review tool

From: Development of the major trauma case review tool

Basic information

Record ID

This is the unique record used by the study team to identify each record

Reviewer ID

Each reviewer has a unique identification number

Date of review

For recording when the review was conducted

Date and time of injury

Key time variables allow for the development of a chronology

Age and gender

Age and gender to allow comparative analysis across groupings and determination of specific areas for education/change within the trauma system that considers age related physiology, age specific injury patterns [36, 37]

Date and time of incident(s)

Key time variables allow for the development of a chronology

Section 1: Patient factors


Such as whether the child is Aboriginal or Torres Strait Islander, culturally and linguistically diverse or a refugee to assist with the identification of potentially vulnerable groups and engagement with appropriate stakeholders when required

Previous location and source of referral

Primary presentation, secondary presentation (e.g. inter-hospital transfer) and source of referral (e.g. self, road ambulance) to assist with mapping of patient flow and identification of potential areas of deficits

Other patient factors

This component attempts to capture the unique characteristics of the patient in the context of their presentation including: complexity and acuity of presentation; behavioural and social factors

Section 2: Presenting problem/diagnosis

Injury mechanism, injuries, and signs and symptoms on presentation

These sections capture the cause and nature of the injury

Section 3: Timeline of events

Timeline of events

Timeline of events in chronological order

Section 4: General incident information

Did the patient die?

To determine whether the child died as a result of their injuries and to assist with further questioning

Phase of care the patient died in (pre-hospital/during transport/in-hospital/which ward?)

To provide a construct on where the incident occurred, allowing monitoring of one point of care or service

Was a toxicology screen/post mortem conducted? If yes, what type was completed and is the report available?

Autopsy reports are a valuable source of information and provide an important adjunct to any investigation of factors potentially contributing to patient mortality [8]

Category of the problem (either clinical, systems or communication)

To assist with the determination of how the clinical deficit occurred and to allow comparative analysis across groupings and determination of specific areas for education/change within the trauma system [27]

Section 5: Specific services involved in the care delivery problem

Specific department and staff involved in the care delivery problem

This multiple choice and free text response section allows for determination of services involved in the care delivery problem

Section 6: Factors contributing to the care delivery problem


Including: lack of medical equipment, medical equipment breakage or failure, equipment failure (design), medical equipment not elsewhere classified, non-medical equipment and medical supplies

Work environment

Including: light, temperature, noise, physical layout, security and work environment not elsewhere classified

Staff action

Including: verbal communication and written documentation issues, medical task failure, monitoring, delay, misdiagnosis, medication issue and human factors not elsewhere classified


Including: physical health, health state, communication issues, medication, toxicology, clothing, and patient characteristics not elsewhere classified

Organisational factors

Including: work practices, policies or guidelines, supervision, organisational resources, work pressure and organisational factors not elsewhere classified

Individual factors

Including: training, experience, fatigue, stress and individual factors not elsewhere classified

Other factors

This is a free text response for factors the reviewer feels are not addressed in the previous categories

Section 7: Outcome

Best description of the incident

How the incident can be best described ranging from clinically preventable to clinically non-preventable death, near miss of death, near miss of incident that did not result in death, preventable error causing lasting disability or no problems identified

Section 8: Positives of care

Positive aspects of care the patient received

This free text response allow for the recording of positives of care the patient received

Section 9: Prior knowledge

Reviewer prior knowledge of the case

Included to identify whether the reviewer had prior knowledge of the case which may affect their review of the case

Section 10: Panel discussion

Summary of review and recommendations

Free text response to allow for a summary of the review and recommendation for corrective strategies after panel discussion

Interview of staff involved?

To allow staff details to be recorded if staff are recommended for interview to obtain further information for completing the assessment