Things falling through the cracks: Information loss during pediatric trauma care transitions

Peter Hoonakker, Abigail Wooldridge, Bat Zion Hose, Pascale Carayon, Ben Eithun, Thomas Brazelton, Shannon Dean, Michelle Kelly, Jonathan Kohler, Joshua Ross, Deborah Rusy, Ayse Gurses

Research output: Chapter in Book/Report/Conference proceedingConference contribution


Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Several clinical teams converge to support trauma care in the Emergency Department (ED); the most severe trauma cases often need surgery in the operating room (OR) and/or are admitted to the pediatric intensive care unit (PICU). These care transitions can result in loss of information or transfer of incorrect information, We interviewed 18 clinicians about communication and coordination during care transitions between the ED, OR and PICU. Clinicians completed a short questionnaire about patient safety during transitions. Results show that, although many services and units involved in pediatric trauma work well together, important patient care information may be lost in the transitions. To safely manage transitions of this fragile, unstable, complex population, we need to better manage the information flow during these transitions.

Original languageEnglish (US)
Title of host publicationProceedings of the 20th Congress of the International Ergonomics Association (IEA 2018) - Volume I
Subtitle of host publicationHealthcare Ergonomics
EditorsSebastiano Bagnara, Yushi Fujita, Riccardo Tartaglia, Sara Albolino, Thomas Alexander
PublisherSpringer Verlag
Number of pages10
ISBN (Print)9783319960975
StatePublished - 2019
Event20th Congress of the International Ergonomics Association, IEA 2018 - Florence, Italy
Duration: Aug 26 2018Aug 30 2018

Publication series

NameAdvances in Intelligent Systems and Computing
ISSN (Print)2194-5357


Other20th Congress of the International Ergonomics Association, IEA 2018


  • Care transitions
  • Patient safety
  • Pediatric trauma
  • Teamwork

ASJC Scopus subject areas

  • Control and Systems Engineering
  • General Computer Science


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