EMS "EVENT" reporting

 

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.

Airline Near Misses video http://www.youtube.com/watch?v=JAhXc9JKT14

Near Miss Fire Fighting Example

Search Reports    http://www.firefighternearmiss.com/index.php/search-reports

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?

·     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 2^nd 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.

 

#4

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.