We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT). Retrospective review of all trauma patients undergoing TT from 6/30/2016–6/30/2019. Multivariable logistic regression identified independent predictors of complications. Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%–53.5%), and early complication increased the likelihood of late complication (4.3%–13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication. TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m2. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes. •Increased TT complication rates are independently associated with placement in the ED.•Urgency, i.e. time to placement, is not associated with increased complication rates.•EM Physician TT placement is associated with increased complication rates.•Malpositioning and early complications are associated with subsequent complications.•TT complications impact hospital length of stay and patient outcomes.