Table 1

Identified errors by category

CategoryError
MedicationTranexamic acid incorrectly or not administered
Tetanus not administered
Mannitol not available or not administered
EquipmentCommunication system malfunction
Raney clips not available
Nursing mobile desk not used
Nursing recording sheet used improperly
HoverMatt not used
Thomas splint not available
Level 1 infuser used incorrectly
Glucometer not used
EnvironmentRecording nurse could not hear
Imaging not available
Neurosurgery unavailable
Orthopedic surgery unavailable
Radiology unavailable
Paramedic overwhelmed with too many tasks
Room not warmed
Sign-in board not used
Identification stickers not used
TrainingImproper technique for spinal precautions
Universal precautions not used
No one trained in focused assessment with sonography in trauma (FAST) available