Ten year analysis of missed injuries at a major trauma centre in South Africa

Introduction: This analysis retrospectively reviews a tertiary trauma service's experience with missed injuries over a decade. Methods: The Pietermaritzburg Metropolitan Trauma Service (PMTS) has accumulated electronic data on all admissions since 2012. This data informs the monthly morbidity and mortality conference, where adverse events are discussed. Records of all missed injuries were reviewed. Results: During the study period there were 17 254 individual patient admissions and 4 624 surgical procedures. A total of 159 missed injuries were identified. Ninety-six were injuries missed on investigation; 60 were missed on CT, 27 missed on x-ray, 1 on blood test, and 8 occurred during an unknown investigation. Thirty-nine injuries were missed during surgery; including thirteen colonic, five small bowel, five gastric, four duodenal, three vascular and three diaphragmatic injuries. Twenty-four injuries were missed on initial assessment, the majority of which were soft tissue injuries. Intraoperative missed injuries resulted in the greatest morbidity. Conclusion: Missed injuries remain a problem in modern trauma care. Injuries missed during initial clinical assessment and on imaging must be excluded by detailed secondary surveys and in depth review of all imaging. Injuries missed at operation carry greater morbidity than those missed outside the operating room. Ongoing vigilance is necessary to reduce the incidence of these injuries.