1) The authors congratulate Thomson and Greaves on their review of missed injuries and the tertiary trauma survey. They note children require unique consideration. 2) The authors acknowledge Hirshberg's classification of missed injury types but note a need to include a Type IV - missed due to failure to review investigation results. Not reviewing results is a systems error hospitals must address. 3) A recent Ugandan study found some missed injuries resulted from delayed radiologist reporting or initial interpretation by junior staff, emphasizing the need for formal investigation review.

1. G Model
JINJ-3641; No of Pages 1
Injury, Int. J. Care Injured xxx (2008) xxx–xxx
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Letter to the Editor
Comment on: ‘‘Missed injury and the tertiary trauma survey’’ tions in a contemporary fashion to ensure optimal patient care.3–5
[Injury 2008; 39:107–114] We would therefore suggest that Hirshberg et al.’s classification
system might be amended to include this form missed injury: Type
IV – missed due to failure to review results of investigations.
Although an obvious systems error, it is only by clearly defining
and reporting these errors that any trauma system can form a basis
Dear Sir,
for future improvements in care to be made.
Thomson and Greaves should be congratulated on their excellent
review of the problem of missed injury and the tertiary trauma Conflict of interest
survey.6 It is worth noting that their review clearly identified
children as a specific sub-population with its own unique set of There are no conflicts of interest with this work.
problems and challenges to those involved in their care.1,5
The authors appraised the classification of patterns of errors of Reference
missed injury including the three groups as defined by Hirshberg
et al. in 1994: Type I – missed during initial examination and 1. Furnival RA, Woodward GA, Schunk JE. Delayed diagnosis of injury in pediatric
trauma. Pediatrics 1996;98:56–62.
investigation, Type II – missed despite directed investigation and 2. Hirshberg A, Wall Jr MJ, Alen MK, et al. Causes and patterns of missed injuries in
Type III – missed due to a diagnostic process interrupted or trauma. Am J Surg 1994;168:299–303.
abbreviated by life-saving emergency interventions.2 The authors 3. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries
and the role of tertiary trauma survey. J Trauma Inj Infec Crit Care
correctly acknowledged that this classification system, in particular 1998;44:1000–7.
Type I and Type II injuries, incorporated a variety of system errors. 4. Okello CR, Ezati IA, Gakwaya AM. Missed injuries: a Ugandan experience. Injury
What was perhaps not so clearly articulated, however, was the 2007;38:112–7.
5. Soundappan SV, Holland AJ, Cass DT. Role of an extended tertiary survey in
need for the treating clinician to actively review the results of detecting missed injuries in children. J Trauma 2004;57:114–8.
investigations. This would include not only the discussion of a 6. Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury
plain radiograph or CT scan with a radiological colleague on the day 2008;39:107–14.
of injury, but also a formal, carefully considered review of all
investigations and their final reports as part of an Extended
Tertiary Survey.5 A recent study in your journal from Uganda A.J.A. Holland*
identified 78 patients with missed injuries of which 17 were due to S.V.S. Soundappan
‘radiological error’; contributing factors included initial interpre- D.T. Cass
tation of the imaging by junior medical staff and delayed reporting Department of Academic Surgery, The Children’s Hospital at
by a consultant radiologist.4 In our review, of the 12 patients with Westmead, The University of Sydney, Locked Bag 4001,
missed injuries identified over a 12-month period, at least one was Westmead, NSW 2145, Australia
missed by a failure of the treating team to review the result of an
investigation that they had requested.5 *Corresponding author
Such a process need not necessarily require the patient to E-mail address: andrewh3@chw.edu.au
remain in hospital, but does require a trauma service and a
dedicated clinician to review both the patient and their investiga- 18 March 2008
0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2008.05.027
Please cite this article in press as: Holland AJA, et al. Comment on: ‘‘Missed injury and the tertiary trauma survey’’ [Injury 2008; 39:107–
114]. Injury (2008), doi:10.1016/j.injury.2008.05.027