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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
Background 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
Equipment 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
Patient 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