Failure Mode Effects Analysis of Re-triage of Injured Patients to Receiving High-level Illinois Trauma Centers

Abstract

Objective:

This study identified failures in emergency inter-hospital transfer, or re-triage, at high-level trauma centers receiving severely injured patients.

Background:

The re-triage process averages 4 hours despite the fact timely re-triage within 2 hours mitigates injury-associated mortality. Non-trauma and low-level trauma centers reported that the most critical failures were in finding an accepting high-level trauma center. Critical failures at high-level trauma centers have not been assessed.

Methods:

This was an observational cross-sectional study at 9 high-level adult trauma centers and 3 high-level pediatric trauma centers. Failure modes effects analysis of the re-triage process was conducted in 4 phases. Phase 1 purposively sampled trauma coordinators, followed by snowball sampling of clinicians, operations, and leadership to ensure representative participation. Phase 2 mapped each re-triage step. Phase 3 identified failures at each step. Phase 4 scored each failure on impact, frequency, and safeguards for detection. Standardized rubrics were used in phase 4 to rate each failure’s impact (I), frequency (F), and safeguard for detection (S) to calculate their risk priority number (RPN; IxFxS). Failures were rank-ordered for criticality based on their RPN.

Results:

A total of 64 trauma coordinators, surgeons, emergency medicine physicians, nurses, operations, and quality managers across 12 high-level trauma centers participated. There were 178 failures identified at adult and pediatric high-level trauma centers. The most critical failures were: (1) insufficiently trained transport staff (RPN = 648), (2) issues transmitting imaging from sending to receiving centers (RPN = 400), and (3) incomplete exchange of clinical information (RPN = 384).

Conclusions:

The most critical failures were limited transportation and incomplete exchange of clinical, radiologic, and arrival timing information. Further investigation of these failures includes several regions is needed to determine the reproducibility of these findings.

Despite decades of research informing Emergency Medical Services field triage criteria for injured patients, 17% to 34% of severely injured patients have been under-triaged upon injury in the field to non-trauma or low-level trauma centers.^1,2 Under-triage of severely injured patients to non-trauma and low-level trauma centers has been associated with higher in-hospital mortality than if taken directly to high-level trauma centers.^3,4

Re-triage has been defined as the emergency inter-hospital transfer of severely injured trauma patients from non-trauma or low-level trauma centers to a high-level trauma center. When re-triage has been done expeditiously within 2 hours, mortality has been equivalent to that of patients taken directly from the field to high-level trauma centers.⁵ Yet, 30% of severely injured patients are not re-triaged.^6–8 Even among successfully re-triaged patients, re-triage takes 4 hours from arrival at the non-trauma or low-level trauma center to arrival at a high-level trauma center.⁹

Prior work demonstrates that lengthy diagnostic evaluations to assess injury diagnosis and severity delayed re-triage.^10,11 Non-trauma and low-level trauma sending centers reported assessment of injury, determination of in-house treatment capabilities, and identification of accepting high-level trauma centers with an available bed were the steps in the re-triage process with the most potential failures that could delay or prevent re-triage.¹² There is a knowledge gap in the steps and failures in the re-triage process from the perspective of high-level trauma-receiving centers.

This study sought to identify the most critical failures to timely re-triage at adult and pediatric high-level trauma centers in a statewide surgical quality improvement collaborative and, for each step, to characterize their underlying causes. The hypothesis was that there are common steps and underlying failures of these steps in the re-triage process at adult and pediatric high-level trauma centers.

METHODS

Study Design

This was an observational cross-sectional study. The analytical approach was a failure modes effects analysis (FMEA).^12,13 The FMEA is an evidence-based, systems engineering technique adapted from high-risk industries to proactively identify the steps at high-level trauma centers in the re-triage process and potential failures that delay or prevent re-triage.^14,15 It has been employed to define re-triage process failures at sending, non-trauma, and low-level trauma centers.¹² The approach had 4 phases: (1) phase I, sampling and recruitment of re-triage team members, (2) phase II, data definition, where participants defined steps (eg, tasks, activities, and communications) in re-triage process, (3) phase III, data collection, where participants identified potential failures at each step in the re-triage process, and (4) phase IV, data analysis, where each failure’s impact (I) on delay in or prevention of re-triage; frequency (F), and safeguards for detection (S) were scored using a standardized rubric adapted for re-triage (Supplemental Digital Content Table 1, http://links.lww.com/SLA/F325).¹¹ The Institutional Review Board at the University approved the study, study number STU00213470. The strengthening the reporting for observational studies in epidemiology checklist was adhered to in drafting this manuscript.

Setting

The setting was 9 adult Illinois designated level I trauma centers and 3 pediatric Illinois designated level I trauma centers participating in the Illinois Surgical Quality Improvement Collaborative, which took part between June 2021 and December 2023.¹⁶ Illinois does not mandate American College of Surgeons verification like most other states in the United States. Illinois trauma center designation is a 2-tiered process based on trauma center adherence to structural requirements, standardized processes, and outcome metrics.¹³ Level I trauma center requirements are similar to those of ACS levels I and II, or high-level trauma centers. Low-level trauma center (level II) requirements in Illinois are similar to those of ACS levels III and IV.¹⁷ Most Illinois trauma hospitals are non-trauma centers.

Participants

Participants were clinicians or staff who were engaged in the re-triage process at their high-level centers in the state of Illinois. Engagement was defined as delivering definitive patient care upon arrival to a high-level center, taking part in information exchange and decision-making with teams at non-trauma or low-level trauma centers, and/or coordinating the transfer process between trauma centers. The participant selection was based on informed consent to participate in 4 recorded, 1-hour focus group sessions, as well as sampling to ensure representation of a variety of roles across different adult and pediatric trauma centers.

Sampling Phase I: Recruitment of Clinicians and Staff

An informational webinar was held across the Illinois Surgical Quality Improvement Collaborative in the summer of 2021 to initiate recruitment. In addition, a 20-minute virtual video presentation was made to the Illinois Department of Public Health Trauma Continuous Quality Improvement Committee where all Illinois designated trauma centers were invited in the fall of 2021. Purposive sampling was conducted with up to 3 emails being sent to surgical clinical reviewers, surgeon champions from the Illinois Surgical Quality Improvement Collaborative listserv, as well as trauma coordinators from the Illinois Department of Public Health Trauma Continuous Quality Improvement Committee listserv. Following the initial recruitment of participants, snowball sampling was then used with representative clinicians and staff being identified by patient care operations managers, quality managers, trauma coordinators, emergency department (ED) medical directors, ED nurse managers, surgeons, emergency medicine physicians, trauma medical directors, and ED nurses. The study team purposively recruited a minimum of 1 trauma surgeon, 1 trauma nurse, and 1 coordinator at each participating level I trauma center to obtain representation of diverse perspectives.

Data Definition Phase II: Definition of Re-triage Process Steps

Virtual meetings between November 2021 and November 2023, each lasting about 60 minutes, were facilitated by a trained non-physician public health PhD candidate. Participants were asked to describe, in their own words, the steps, including tasks and communications that each person engaged in during the re-triage process. Participants were asked to begin describing the process following a request from a non-trauma or low-level trauma center for re-triage. The virtual meeting sessions were audio-recorded and transcribed verbatim with detailed field notes also taken. The identified tasks and/or communications of each step were placed in sequence in the re-triage process. Two re-triage process maps, one for high-level trauma centers receiving adults and high-level trauma centers receiving children were created. The maps were then reviewed with participants for feedback and correction.

Data Collection Phase III: Failure Identification in Each Step

Participants were asked in a second 60-minute virtual focus group to proceed through each identified step in the process map they previously created between November 2021 to November 2023. They were asked to identify potential failures with each step. Participants were best able to speak to different failures based on their roles and knowledge of the common barriers and facilitators of each step. Participants were invited to identify potential underlying causes of each failure.

Data Analysis Phase IV: Identified Failure Scoring

Participants ranked each failure based on impact on the re-triage process, frequency, and existing safeguards to mitigate failure using a standardized 10-point scale between November 2021 to November 2023. The definition and validation of the scoring rubric were detailed in a prior study.¹¹ Participants had the scoring rubric on hand and were oriented verbally in the third 60-minute virtual focus group. Impact scores of “1” were failures that did not delay re-triage beyond 2 hours, whereas “10” indicates failures that resulted in life-threatening delays to re-triage within 2 hours. Frequency scores of “1” indicated a failure that almost never occurred (1/10,000 re-triage cases), whereas “10” indicated failures that occurred in almost every re-triage case (1/10+). A safeguard score of “1” was a failure with automatic means of detection resulting in near-certain prevention, whereas “10” was assigned to failures with no feasible method of detection or prevention.

The study team multiplied impact, frequency, and safeguards scores provided by participants to get the final risk priority number (RPN) of potential failures that could disrupt the re-triage process. The minimum possible score for each failure was 1 and the maximum possible score was 1000.

Participant Checking

The adult and pediatric process maps were reviewed by the study team for shared common steps in the re-triage process at receiving high-level trauma centers between December 2021 to December 2023. Non-trauma center, low-level, and high-level trauma center participants were presented with the process map, scored risk table, and the rank ordered failures in the final 60-minute virtual focus group facilitated by a non-clinician PhD candidate researcher with previous experience in this technique. Participants provided minor clarifications, usually related to differences in frequency scoring due to variations in geography, staffing, transportation options, and receiving trauma centers. However, the corrections did not result in any modification of the rank ordering of the failures. Further, participants confirmed that the highest-risk failures were major obstacles to appropriate and timely re-triage of trauma patients.

Statistical Methods

The average impact score was calculated for each failure across all adult level I trauma centers and pediatric level I trauma centers separately. Failures were rank ordered based on their impact score for adult and pediatric level I trauma centers separately. The average frequency score out of 10 points was calculated for each failure across all adult level I trauma centers and across all pediatric level I trauma centers separately. Failures were rank ordered based on their frequency score for adult and pediatric level I trauma centers separately. The average safeguard score was calculated for each failure across all adult level I trauma centers and all pediatric level I trauma centers separately. Failures were rank ordered based on their safeguard score for adult and pediatric level I trauma centers separately. Each failure’s impact, frequency, and safeguard scores were multiplied together to yield each failure’s RPN averaged for adult Level I trauma centers. The RPN was averaged across all pediatric level I trauma centers separately.

RESULTS

A total of 64 re-triage team members from 12 receiving high-level adult and pediatric trauma centers completed an FMEA describing their institution’s re-triage process for severely injured patients (Table 1). This included 57 re-triage team members across 9 adult high-level centers and 7 re-triage team members from 3 pediatric level I trauma centers. There were 6 adult level I trauma centers and 2 pediatric level I centers represented by teams that included at least 1 trauma surgeon, 1 trauma nurse, and 1 coordinator. Three adult level I centers and 1 pediatric level I center were represented by teams that did not include a trauma nurse.

TABLE 1.

Participants in Failure Mode Effects Analysis of Re-triage Process of Severely Injured Adults and Children at Illinois Adult and Pediatric High-level Trauma Centers From the Illinois Surgical Quality Improvement Collaborative 2021–2023

Role	No. of participants (%) (N = 64)
Trauma medical director	10 (15.6)
Trauma surgeon	15 (23.4)
Emergency medicine physician	4 (6.3)
ED nurse manager	4 (6.3)
Trauma manager	3 (4.7)
ED director	6 (9.4)
Trauma coordinator	15 (23.4)
Patient care operations manager	4 (6.3)
ED nurse	2 (3.1)

Re-triage Process

Participants at receiving adult level I centers identified 24 steps in the re-triage process, spanning the initial call from sending a non-trauma or low-level trauma center to a patient’s re-triage to a receiving high-level trauma center (Fig. 1). Teams at the pediatric level I trauma centers identified 26 steps, spanning the initial call from usually an adult trauma center to a child’s re-triage to a receiving pediatric trauma center (Fig. 2). Two main shared common phases that emerged in the re-triage process were matching patient needs with receiving high-level center resources and movement of patient and data between centers. Participant adult and pediatric level I trauma centers were mapped by Illinois Department of Public Health Emergency Medical Service Regions on top of the geographic location depicting their relative distance (Fig. 3).

FIGURE 1.

Adult re-triage process at receiving Illinois adult high-level trauma centers from the Illinois Surgical Quality Improvement Collaborative 2021–2023. Green circle indicates step initiating process. Box indicates step advancing process. Diamond indicates the decision step. Circle indicates the process connector. Red oval indicates step ending process.

FIGURE 2.

Pediatric re-triage process at receiving Illinois pediatric high-level trauma centers from the Illinois Surgical Quality Improvement Collaborative 2021–2023. Green circle indicates step initiating process. Box indicates step advancing process. Diamond indicates the decision step. Circle indicates the process connector. Red oval indicates step ending process.

FIGURE 3.

Geographic locations of each participating adult and pediatric level I center, relative distance, and emergency medical service regions. Light purple area indicates EMS region 2. Dark orange area indicates EMS region 6. Green area indicates EMS region 7. Light orange area indicates EMS region 8. Turquoise area indicates EMS region 9. White area indicates EMS region 10. Purple area indicates EMS region 11. Red marker indicates adult level I trauma center. Yellow marker indicates adult and pediatric level I trauma center. Orange marker indicates the pediatric level I trauma center. EMS indicates emergency medical service.

Matching Patient Needs With Receiving High-level Center Resources

The first shared common step in the re-triage process at receiving high-level adult and pediatric trauma centers was that re-triage began when sending centers contacted a receiving high-level trauma center. The second shared common step was receiving high-level centers determined whether they could match reported patient’s needs with their resources (available staffed beds, available operating rooms, and specialists for specific injuries). This phase occurred between steps 1 and 3 in the process at adult centers and steps 1 to 7 at pediatric centers.

Common Steps in Movement of Patient and Data Between Centers

This phase in the re-triage process involved many stakeholders at both sending and receiving high-level centers working together. The first shared common step was obtaining a transportation team, often with critical care capabilities, for the sending center. Occasionally this was done by the sending center and sometimes it was done by the receiving center. The second shared common step was obtaining verbal handoff of patient clinical data from the sending center to the receiving high-level centers. Usually, this happened by the sending center reaching out, and finding who to talk to and getting a hold of them were sub-steps that could be challenging. The third shared common step was transmitting hard copies of results (ie, imaging, laboratory results) from the sending center to the receiving high-level centers. Very few centers had shared health record platforms necessitating hard copies, which had associated challenges. The fourth shared common step was the relay of an estimated time of arrival receiving high-level resources would have resources on stand-by for the patient upon arrival. This entire phase occurred between steps 4 to 8 at adult centers and steps 8 to 11 at pediatric centers.

Failures at Adult Receiving High-level Trauma Centers

Multiple failures were identified for each step of the re-triage process at adult high-level trauma centers, for a total of 178 failures. Scores for highest impact failures at adult high-level trauma centers ranged (1) issues transmitting imaging, (2) insufficiently trained transport staff, and (3) no available beds at high-level centers (Supplemental Digital Content Table 2, http://links.lww.com/SLA/F325). The most frequent failures were (1) no transport crew available, (2) insufficiently trained transport staff, and (3) no imaging transmitted (Supplemental Digital Content Table 3, http://links.lww.com/SLA/F325). Failures with the fewest safeguards for detection or mitigation were (1) insufficiently trained transport staff, (2) delivery of unnecessary tests/treatments before initiating a re-triage request, and (3) no estimated time-to-arrival (ETA) from the transportation team (Supplemental Digital Content Table 4, http://links.lww.com/SLA/F325). The RPNs at adult trauma centers ranged from a minimum of 28 to 648. The 3 most critical failures were (1) insufficiently trained transport staff (RPN = 648), (2) issues transmitting imaging (RPN = 400), and (3) incomplete exchange of clinical information (RPN = 384; Table 2).

TABLE 2.

Top 10 Most Critical Failures in Failure Mode Effects Analysis of Re-triage Process of Severely Injured Adult at Receiving Illinois Adult High-level Trauma Centers From the Illinois Surgical Quality Improvement Collaborative 2021–2023 by RPN

Step	Step description	Potential failures	Potential effects	RPN
7A	Patient transported to a high-level center	Insufficiently trained transport staff	Transportation delays	648
6B	Nurse-to-nurse handoff report	Issues transmitting imaging	Imaging needs to be done at a high-level center	400
6B	Nurse-to-nurse handoff report	Incomplete exchange of clinical information	Delays assembling the necessary clinicians, staff, and specialists at patient arrival	384
7B	EMS gives ETA 10 min before arrival	No ETA from the transportation team	Delays assembling the necessary clinicians, staff, and specialists at patient arrival	320
7A	Patient transported to a high-level center	Inclement weather	Transportation delays due to the use of ground instead of air transport	320
2B	Transfer Center Coordinator at high-level center pages trauma surgeon	Imaging unreadable	Evaluation and decision to accept re-triage candidate delayed	315
2B	Transfer Center Coordinator at low-level/non-trauma center contacts high-level center trauma surgeon	Trauma surgeon in OR/trauma resuscitation and unavailable	Delays calling low-level/non-trauma center back about re-triage candidate	294
14	Imaging needed?	No x-ray tech available	Delay completing necessary imaging	280
1B	Low-level/non-trauma hospital calls high-level transfer center for an ICU-to-ICU transfer	Patient requires multiservice coordination (eg, hand amputation)	Delay connecting to necessary specialists at the high-level center	245
12	Patient unstable: direct to the OR?	No OR available	Delay delivering care	216

EMS indicates emergency medical service; ICU, intensive care unit; OR, operating room.

Failures at Pediatric Receiving High-level Trauma Centers

Similarly, multiple failures were identified for each step in the re-triage process at pediatric high-level trauma centers, for a total of 101 failures. Failures with the highest impact were (1) no available beds at the pediatric center, (2) inclement weather, and (3) incomplete exchange of clinical information (Supplemental Digital Content Table 5, http://links.lww.com/SLA/F325). The most frequent failures were (1) no ETA from the transportation team, (2) insufficiently trained transport staff, and (3) multiple patients requiring transport to the pediatric center (Supplemental Digital Content Table 6, http://links.lww.com/SLA/F325). Failures with the fewest current safeguards for detection or mitigation were (1) inclement weather, (2) incomplete exchange of clinical information, and (3) lack of necessary specialized trauma-related care (Supplemental Digital Content Table 7, http://links.lww.com/SLA/F325). The RPNs at pediatric trauma centers ranged from a minimum of 12 to 294. The 3 most critical failures based on RPN (1) lack of necessary specialized trauma-related care (RPN = 294), (2) lack of ETA by transport team (RPN = 216), and (3) inclement weather (RPN = 168; Table 3).

TABLE 3.

Top 10 Most Critical Failures in Failure Mode Effects Analysis of Re-triage Process of Severely Injured Children at Receiving Illinois Pediatric High-level Trauma Centers From the Illinois Surgical Quality Improvement Collaborative 2021–2023 by RPN

Step	Step description	Potential failures	Potential effects	RPN
1A	Sending hospital calls communication center for an ED-ED pediatric transfer	Patient has an isolated injury requiring specialized pediatric care	Delays assembling the necessary specialists at patient arrival	294
10B	EMS gives ETA 10 min before arrival	No ETA from the transportation team	Delays assembling the necessary clinicians, staff, and specialists at patient arrival	216
9	Transport team goes to the sending center to pick up patient	Inclement weather	Transportation delays due to the use of ground instead of air transport	168
1B	Sending hospital calls communication center for an ICU-ICU pediatric transfer	No available beds at pediatric center	Time required to find a staffed bed for a critically injured child	160
6	Sending center transmits the patient’s hard copy medical record to the pediatric center’s communication center	Issues transmitting imaging	Imaging needs to be done at the high-level center	150
10B	EMS gives ETA 10 min before arrival	EMS stuck in traffic	Delays arrival at high-level pediatric center	150
2B	Communication center calls pediatric trauma surgeon	Patient requires multiservice coordination with the PICU	Delay connecting to intensivist before accepting pediatric patient	144
9	Transport team goes to the sending center	Sending center unable to receive air transport service	Delay transporting a pediatric patient	144
15	Imaging needed?	Pediatric trauma surgeon in OR/trauma resuscitation and unavailable	Delay completing imaging	100
9	Transport team goes to the sending center	Patient decline requires stabilization before departure from the sending center	Delay transporting the patient to a pediatric center	90

EMS indicates emergency medical services; ICU, intensive care unit; OR, operating room; PICU, pediatric intensive care unit.

DISCUSSION

This study sought to identify and characterize failures in the re-triage process of trauma patients from non-trauma and low-level trauma centers to high-level trauma centers that are part of Surgical Quality Improvement Collaborative. Common shared failures in the re-triage process of both adult and pediatric high-level trauma centers are lack of or inadequacy of critical care transportation and incomplete patient clinical information exchange.

The FMEA methodology has been used to evaluate complex processes in health care,^18–21 as well as expeditious transfer between hospitals for conditions like coronavirus disease 2019,^22,23 neurocritical care,²⁴ transplantation,²⁵ and stroke.²⁶ Studies employing this approach to examine time to definitive emergency care described how interventions aimed at critical failures in the process effectively protected against disruptions to information transfer between care teams.^20,27 Other risk assessments specific to emergency care have shown that well-defined process owners help minimize information gaps and improve care during handoffs between ambulance and ED teams,²⁸ as well as between receiving and sending centers.^29,30

The key implications of the study findings are the need for improved coordination to secure appropriate transportation, as well as more timely, efficient, and accurate exchange of clinical information. It is important to note that re-triage failures are perceived differently by non-trauma and low-level centers compared with high-level trauma centers because they see the problem at different time points along the pathway. Most proximally in the pathway, non-trauma and low-level trauma centers perceive the failures that prevent quickly (1) establishing who needs to be re-triaged to a higher level of care and (2) finding an accepting high-level center.¹² High-level trauma centers participate in the pathway more distally, after the need to re-triage has been established and the high-level trauma centers accepted the patient. Although we did hear that re-triaged patients were sometimes “not as billed,” the highest-ranking failures perceived by the high-level trauma centers were concentrated on being able to move the patient and data quickly. To bridge these different perspectives, we have been designing shared solutions addressing the overlap in the perceived failures at non-trauma, low-level, and high-level trauma centers (Fig. 4).

FIGURE 4.

The re-triage pathway and the overlap in the perceived failures at non-trauma, low-level, and high-level trauma centers. Orange boxes indicate the first 2 phases in low-level/non-trauma center re-triage process. Orange gear icon indicates the final phase in low-level/non-trauma center re-triage process. Blue gear icon indicates the first 2 phases in the high-level trauma center re-triage process. Dashed lines denote concurrent and interrelated re-triage process phases at high-level and low-level/non-trauma centers that are focused on shared solutions. Blue box indicates the final phase in the high-level trauma center re-triage process.

One promising approach is through Medical Operations Coordination Centers. Medical Operations Coordination Centers have been described as entities that provide a mechanism for aligning resources and information exchange between sending and receiving hospitals during patient inter-hospital transfer for time-sensitive conditions like severe injury.³¹ Medical Operations Coordination Centers have done this by operating shared dashboards with bed capacity data while serving as third-party facilitators of transportation and information exchange between centers. Although they have required initial resources to implement and sustain, the return on investment, as measured by preventable mortality reduction and more efficient resource use, has been well documented across multiple states.^32–34

Beyond Medical Operations Coordination Centers, there are also hospital-level solutions that were identified by stakeholders. These included Virtual Private Networks for imaging sharing between hospitals, auto-accept criteria for severe injury, communication mechanisms between hospitals, codified hospital transfer agreements/informal buddy systems between non-trauma, low and high-level trauma centers, and earlier activation of transport resources. Further detailed solutions will be presented in a forthcoming “User-Centered Design” manuscript.

There were several limitations to this study. First, the FMEA approach was subject to observer bias because it relies on the perspectives of each participant, however, data about the impact, frequency, or existing safeguard of a failure are simply not available in the health care setting. A participant’s role in the re-triage process, years of experience in the role, and types of involvement in trauma cases may bias their assessments. However, the study mitigated this bias by drawing on a diverse group of participants with varied roles at varied types of centers. The study may also have been prone to sampling bias, which we sought to mitigate by sampling from 2 different groups of stake-holders, including Surgical Quality Improvement Collaborative and IDPH Trauma Continuous Quality Improvement Committee. Third, most participants were from a similar geographic area increasing the risk of selection bias and potentially limiting the generalizability of the most common failures to other regions. However, most of the state’s population is also concentrated in this geographic area. Fourth, 3 adult and one pediatric high-level trauma center participant teams did not include a trauma nurse. Under-representation may have led to bias in identifying and ranking the earlier steps in the re-triage process where trauma nurses were the content experts on the teams. Fifth, this study was conducted during and in the years after the coronavirus disease pandemic. This rare and unprecedented event in the era of modern health care may contributed to the availability bias of participants because of concurrent undue stress related to staffing and structural resource shortages. Yet, since these shortages were nationwide, the impact of this bias on the generalizability of the findings of this study was likely small.

CONCLUSIONS

The FMEA of the re-triage process revealed that it is a multistep process with multiple failures at each step. The findings of this study suggest that the most critical failures in the re-triage process at high-level trauma centers occur during steps dedicated to arranging patient transport and the exchange of patient clinical data. The common shared critical failures in the re-triage process at both adult and pediatric high-level trauma centers are lack of or inadequate transport, as well as, incomplete, inadequate, or lack of exchange of clinical information needed to mobilize resources and clinical care teams at the high-level trauma centers. Given the limited geographic variation of the hospitals included in this study, further investigation of these failures includes several regions is needed to determine the reproducibility of these findings.