EMS Event Reporting Program Patient Safety First

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EMS Event Reporting Program Patient Safety
First

• Effective December 1, 2007
• Contra Costa EMS Agency

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EMS Event Reporting Design

• Formerly Unusual Event Reporting
• Redesigned patient safety and recognition program
• Prioritizes patient safety
• Clear line of reporting and follow-up

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Sowhat is an EMS Event?

• Any event that has led to or has the potential to
  lead to an adverse patient outcome
• Great Catches
• Community event that may cause public concern
• Exemplary care in the field
• Events that represent a threat to public health
  and safety defined by 1798.200 CA HS Code

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Why is this a better system?

• Helps us focus on what is REALLY important
• Patient and Provider Safety
• Exemplary Care in the field
• Early notification system
• Pink Flags
• Red Flags
• When you catch problems when they are small they
  stay small.Gordon Graham

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Patient SafetyWhat the Experts Know

• Events cause enormous amount of injury, suffering
  and death
• They are preventable
• Multiple events contribute to the most serious
  outcomes
• Punishing people does little to improve overall
  system safety.

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Root Causes of Patient Safety Events

• Patient care delays causing harm or death (JCAHO)
• Communication (84)
• Patient Assessment (75)
• Orientation and Training (46)

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Root Causes

• Fire Fighter Deaths (NIOSH)
• gt20 firefighter deaths occur on roadways
• Root causes seat belt use and scene safety

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Whats in for the EMS system?

• Focus on positive corrections
• Early identification of system problems
• Promotes accountability and respect
• Reduces conflicts between HR, HIPPA, agency
  privacy practices
• Recognition system of field care excellence

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Implementation Problem 1 We punish people
for making mistakes

• The single greatest impediment to improving
  system-wide safety
• Most of what we deal with is Human Error
• What is Human Error? The honest mistake.

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What You Need To KnowChange takes time
Movement in Reporting as the Learning Grows
Report on equipment Report on events you
observe Report on own human error Report on own
knowing violation of policy
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EMS Provider Responsibility

• Patient safety
• Accountability
• Report

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Who can report
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EMS Event Reporting Jan-Dec 2007
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EMS Event CharacteristicsWe have the same
issues
100 of events where communication played a
factor also affected patient care. AHRQ
Communication is a major factor in gt65-75 of
sentinel events
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High Risk Communication

• Patient Handoffs (2006 EMS Annual Report)
• gt 102,000 handoffs
• 20 increase from 2005
• Potential for 4 or more different communications
  for each patient transport
• First Responders to 911 Transport
• May involve up to 5 responders (Fire Transport)
• Transport to ED personnel
• May involve 1-2 medics and 2 or more nurses, MD
• Base Hospital Communication
• Receiving Hospital Communication

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Evidence Based Patient Safety Communication
Models
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Scenario Things didnt go according to plan

• Mary Medic reports a 2 hour offload delay at
  an ED with a 22 year old patient in active labor.
  
• Patient ended up delivering in the ambulance

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Scenario Great catch

• Joe Medic during a routine check of equipment
  finds a defibrillator not working. The device is
  replaced but the time it took could have caused a
  delay if his unit had been dispatched.

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Scenario Community event causing public concern

• Any event of interest to the press.
• Multi-casualty Incidents
• Report of ambulance or fire vehicle accidents
• EMS needs our providers eyes and ears!
• Report occurs through chain of command

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Scenario Exemplary Care

• First responder ALS medics Jones and Allen arrive
  at a scene of a near-drowned 3 year old. They
  provide excellent CPR and the child has ROSC.
• Response time is excellent and due to the efforts
  the child makes a full recovery.

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Scenario Threat to Public Health and Safety

• Citizen Smith calls reporting he believes his
  elderly mother received an arm injury while being
  transported. He is angry and very upset. The
  medics involved report the situation was chaotic
  and the scene unsafe.

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Stakeholder ParticipationContra Costa QI
Committee Constituents

• San Ramon Fire
• Moraga Orinda Fire
• East Contra Costa Fire
• Richmond Fire
• Contra Costa EMS
• JMMC-Walnut Creek

• Con Fire
• AMR
• El Cerrito Fire
• Pinole Fire
• Rodeo Hercules
• JMMC-Concord

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Questions