To determine the complication rate and risk factors associated with tube thoracostomy (TT) in the trauma patient. Retrospective hospital chart review. Level I trauma center. Four hundred twenty-six consecutive patients who underwent TT were initially reviewed; 47 deaths occurred unrelated to TT placement. The remaining 379 patients required 599 tubes and composed the study population. The determination of adverse outcomes related to TT, including thoracic empyema, undrained hemothorax or pneumothorax, improper tube positioning, post-tube removal complications, and direct injuries to the lung. The overall complication rate was 21% per patient. Although complications were not related to the Injury Severity Score, the presence of shock, admission to the intensive care unit, and the need for mechanical ventilation were associated with the increased incidence of complications. There were fewer complications (6%) when the TT was performed by a surgeon compared with TT performed by an emergency physician (13%, P < .0001) or TT performed prior to transfer to our hospital (38%, P < .0001). Tube thoracostomy is associated with significant morbidity. The striking difference in the complication rate between surgeons and other physicians who perform this procedure suggests that additional training may be indicated.