Dr. Deming, a well-known quality expert described errors
being primarily management issues. He stated that “the problems are with the
system, and the system belongs to management.” Another way to look at this is
that you get the results that your system is supposed to get. If you can’t
identify the errors and the system related to the issue then you can’t improve.
He famously used the plan, do, study, and act method of process improvement.
Possibly the most important first step is to identify the problem, and one of
the best ways to do that is to have some type of easy-to-use reporting system.
The need for a tool for reporting when safety events occur
is key in the process of creating a culture of safety. The anonymous reporting
of safety-related data can identify potential hazards and trends that can then
be addressed appropriately at all levels. Today I will talk a little about a
reporting tool that has been in use for EMS for a little more than a year and
is showing some great data.
The EMS Voluntary Event Notification Tool (EVENT) http://event.clirems.org/ reporting system
is a tool that is meant for EMS providers to use to gather information about
hazardous events that can occur in EMS. The EVENT collects information about 4
different types of occurrences; these include patient safety events, near miss
events, violence events, and line of duty deaths.
EVENT is a program of the Center for Leadership, Innovation,
and Research in EMS (CLIR) with sponsorship from a number of national and
international EMS agencies like NAEMT and the National EMS Management
Association. This was in response to the general focus on errors in medicine
identified over a decade ago by the national Institute of Medicine (IOM), which
pointed out the fact that 44,000 to 98,000 patients die a year in the
healthcare system due to errors.
The idea of a reporting system is something that has come
out other industries like the airline industry and in fire-fighting. Here
is the main fire fighting close call website http://www.firefighternearmiss.com/index.php/home
. They have a very robust reporting system and you can search by type of run,
fire, extrication, EMS, etc. and contributing factors like situational
awareness, training, or human factor. A quick search of EMS related event using
those contributing factors stated previously I found a run in Indiana involving
a simple “medical alarm” run which ended with someone with a gun that ended up
needing tazed. There is even a section where the responder can reflect on
lessons learned, like having better awareness of “unknown scenes” and proper approach
on scenes (knocking on door, announcing as Fire Department, Paramedics, EMTs,
etc., and keeping body to side of door). I will reprint this particular report
at the end of this article.
Some confusion exists in determining what the difference is
between a “near miss” and a patient safety event. The simplest explanation is
that if after an event you say “whew… that was close,” and no injury occurred to
anyone, your partner stopped you before injecting a wrong medication, then it
was a near-miss. If contact was made, a cot actually fell 2 clicks
accidentally, or a patient was actually injected with a wrong medication (or
dose) than it was a “hit,” a patient safety event has occurred. Line of duty
deaths are self-explanatory.
The last section that EVENT reports are made on is an area
of growing concern that I have already written about, violence against EMS. FAR
too often we get injured by patients and shrug it off as “part of the job” or
rationalize not reporting it since the patient was having a medical condition
or was somehow impaired. Until we start reporting these seemingly mundane occurrences,
even the minor ones it will continue to be a silent epidemic.
Out of the 4 different reports you can made, the violence
one is the shortest form, and may only take 5 or less minutes to fill out. The
other reports are more in depth and may take longer. Any individual practitioner
or supervisor can fill out the reports.
One of the obvious things that seems to be missing from
EVENT is a reporting system about provider injuries. This data is usually collected
by state and national occupational health and safety agencies. Some good
reports have been made using this data and general statistics from the past few
years are available on these CDC webpages http://www.cdc.gov/niosh/topics/ems/
.
I would suggest that EMS organizations begin having their
supervisors adding information gathered in their field personnel’s incident
reports into this system. I would also suggest that organizations should
actively promote the use of the near miss reporting system or other systems if they
think they may have an event or wish to remain anonymous about an event. The
most important thing is that the information is shared and lessons are learned.
EVENT sends out information about the different reporting systems
every quarter. These reports can be great sources of information to managers
and even trainers. Trends can be identified and potentially deficient systems
and processes can be changed before an incident occurs at your organization. Trainers
and educators can identify where education has lacked in particular areas. A
great example of this is in the treatment of Ventricular Tachycardia w/pulses.
After delivering a synchronized shock, the monitor defaults back to
unsynchronized, and if not caught the provider can easily deliver an
unsynchronized shock at the next treatment iteration. One drawback to this reporting
is that sometimes brand names are redacted to help prevent potential
sabotaging.
I hope this topic has been enlightening for you all. So
remember that anonymous reporting like the EVENT reporting system for EMS is a
key ingredient in creating a true culture of safety in any organization. Please
consider spreading the word of EVENT reporting as the more awareness and
reporting the better designed systems we can have that will ensure ourselves
and our patients have better outcomes.
The EMS Voluntary
Event Notification Tool
http://event.clirems.org/
For reports on previous
incidents select types of forms and you should find reports option on the left
side.
Near Miss Fire
Fighting Example
Report Number: 12-0000016
Report Date: 01/27/2012 08:50
Synopsis
Patient wakes up with gun in hand.
Demographics
Department type: Combination, Mostly paid
Job or rank: Lieutenant
Department shift: 24 hours on - 48 hours off
Age: 43 - 51
Years of fire service experience: 21 - 23
Region: FEMA Region V
Service Area: Suburban
Event Information
Event type: Non-fire emergency event: auto extrication,technical rescue,emergency medical call,service calls,etc
Event date and time: 01/27/2012 05:21
Hours into the shift:
Event participation: Involved in the event
Weather at time of event: Not reported
Do you think this will happen again?
What were the contributing factors?
Report Date: 01/27/2012 08:50
Synopsis
Patient wakes up with gun in hand.
Demographics
Department type: Combination, Mostly paid
Job or rank: Lieutenant
Department shift: 24 hours on - 48 hours off
Age: 43 - 51
Years of fire service experience: 21 - 23
Region: FEMA Region V
Service Area: Suburban
Event Information
Event type: Non-fire emergency event: auto extrication,technical rescue,emergency medical call,service calls,etc
Event date and time: 01/27/2012 05:21
Hours into the shift:
Event participation: Involved in the event
Weather at time of event: Not reported
Do you think this will happen again?
What were the contributing factors?
· Situational Awareness
· Other
What do you believe is the loss
potential?
· Other
· Life threatening injury
Event Description
This
morning the engine and paramedic crew responded to a medical alarm with no
contact. We were advised of key
location information over the Mobile Data Computer and upon our arrival we
checked for the key but did not find it.
I asked if the alarm company had any contact information for a key
holder before we forced entry into the residence. I was advised that they located a possible
key holder at the residence. A police officer responded to see if they had a
key for the residence. The police officer returned with a key for the home and
entry was made.
Upon
entry into the home, the police officer and I announced our presence with no
answer or indication anyone was present in the home. A secured door was located on the first floor
in the northeast corner of the home. The
lock was a simple push lock and it was unlocked using an ink pen. The police officer opened the door and saw an
elderly man come up from the bed with a gun and the police officer announced
that there was a man with a gun. The
police officer attempted to talk to the subject. I informed the police officer that I was
notifying dispatch of the man with a gun and additional back-up personnel. I then began to work on how to get the rest
of the crew out of the living room and out of the house safely. I advised the crew one at time to head across
the living room back towards the front door and out of the building. Additional police officers arrived on
location and after a short time they advised that the scene was secure. The patient had been tased once in the
stomach. The “Taser” probes had been removed by police officers prior to our
re-entry. Paramedics treated the patient
and transported him.
Lessons Learned
It
is important when responding to medical alarms to ensure we are requesting the
assistance of law enforcement, especially if there is a need to force entry or
even use a key provided. You can startle
a homeowner and they might have a gun and use it. Worse yet, they might be unstable due to a
medical condition. Staying aware of your
surroundings and keeping a way out to retreat in the event that the incident
goes south is very important.
EVENT Violence against provider Examples from 2nd
Quarter 2013
#2
While
caring for a mentally ill female who was under the influence of alcohol she
struck the paramedic twice in the head.
#3
While
working in the apparatus bay at the fire station, personnel noticed a male
staggering across the outside ramp near the overhead doors. "Walk-in"
calls are not uncommon at this fire station and the crewmembers immediately
approached the man to assess his condition and render aid. All members noted
that man exhibited signs and symptoms of alcohol intoxication. The crew walked
with the individual to the staff door at the eastside of the station, where
several crewmembers stayed with him while another went inside to retrieve
medical equipment. In that employee absence, the individual threw a punch with
his right fist, striking the other employee in the face. The employee did not
fall or lose consciousness, but rather with crew assistance, restrained
individual on the ground and called for law enforcement assistance over the
radio. Crews reported the individual did not appear to be agitated by their
presence or assistance and that the punch was not provoked or expected. Law
enforcement responded to the scene with two officers, who placed the individual
into custody, restrained with handcuffs. Examination of crewmember noted minor
soft tissue injuries, did not request further medical evaluation and remained
on duty.
Called
for chest pain, double critical care paramedic crew. Performed normal exam and
12-lead on patient in her home. Patient had no desire to go to the hospital and
refused transport. While putting away the ECG cables the patient screamed and
grabbed my partner and managed to scratch his face a couple times. He was defending
himself from her unarmed strikes with our tablet computer. I dropped the ECG
cables and pulled her off of him, and she then attempted to bite my arm. I was
able to push her onto the bed and that time her boyfriend ran into the room and
restrained the patient. For safety and since the patient had already signed all
the forms and did not want to be transported we left the scene and reported the
incident to management right away. They were not interested in the report since
we were no longer on scene. No follow up was ever performed by the company and
we were disciplined for the incident later because the patient called and complained
about us.
#5
Pt was
possibly high on unknown substance. Pt was swinging at firefighters and EMS
went behind patient to take him to the ground. Pt was fighting for 10 minutes
and IM versed was given.
#6
Patient was intoxicated and grabbed at hair and struck victim; also
verbally abusive.
#7
Crew
called to psychiatric floor of a medical clinic for a "man down." 28
y/o patient was now calmly sitting in chair with parents & MD stating pt.
was found collapsed on lobby floor earlier. During assessment & without warning,
pt. punched attendant in head resulting in incapacitation & minor
concussion. After 2nd outburst damaging property in exam room, pt. transported
by a 2nd crew. Pt. also attempted to punch medic on transport crew.
#8
During
the course of treatment, patient became physically assaultive. Patient was
advised to cease and desist assaultive actions; patient did not. The violent
actions of the patient were noted to escalate, in which the provider felt that
an imminent danger existed. The patient was physically restrained by provider
in a manner that did not impede airway, breathing or circulation, until police
presence was available. The patient was handcuffed by law enforcement, with
hands in front of the patient, and patient’s handcuffed hands were restrained
above and behind the patient's head. Once the ability of the patient to assault
providers, the patient calmed and became compliant with legal orders.
