Top 10 things you can do today to improve patient safety

Blair L. Bigham

August 2011

It’s been a year since the Canadian Patient Safety Institute published “Patient Safety in EMS: Advancing and Aligning Patient Safety,” and two years since the Niagara Patient Safety Roundtable where EMS Chiefs, physicians, paramedics and safety experts identified the top nine priorities to improve patient safety in EMS. Since then, a lot has changed: The United States has started down the path of shifting EMS safety culture through a partnership of the federal government and the American College of Emergency Physicians, anonymous patient safety data has started to flow, and researchers have seen an increase in funding through patient safety grants. But I have to ask… what’s changed on the road where you work? Where I work, I’ve seen some modest advances, but for the most part it’s still status-quo.

This always perplexes me. I get emails and phone calls a couple times a week from EMS leaders across the world asking how they can make their EMS system safer. I’ve flown to a dozen cities to speak on cultural shift and reducing adverse events. I’ve published papers, done media interviews, and even contemplated climbing a mountain to shout at the top of my lungs about improving safety. But none of this seems to have changed reality out on the street. We have yet, as an industry, as a profession, adopted a culture of safety. So here I am, at the top of the Mount CEN, with the Top 10 things you can do today to improve patient safety in your emergency medical service.

10. Get informed. Read the report.

    Patient safety is a new concept to the EMS world. Our traditional methods of dealing with error and accidents have been shown to be ineffective. Lessons have been learned, techniques perfected, by the aviation and hospital industries. A lexicon has evolved, and new attitudes are required. This means we need to do a little self-study to educate ourselves about what patient safety really is, and isn’t, and how it fits into our world. The report is free. Just Google “Patient Safety in EMS” and click on the second link for the PDF.

9. Be on the lookout.

   Adverse events happen everyday. Near misses happen on every call. Usually, we brush these off: “No harm, no foul,” we say. This is a deadly attitude. No harm? We got lucky. More specifically, our patient got lucky. Start to look for the system and behavioural components in your EMS day that have the potential to lead to an adverse event. Recognition is the first hill that must be overcome to make systems and our own practice safer.

8. Implement a Safety Management System (or ask your boss to implement it).

   A recent series of articles in EMS Best Practices by Michael Greene, a safety expert, provides an overview of how to build a Safety Management System (SMS). SMS ensures you have the processes in place to systematically identify and mitigate the effects of unsafe practices. The four pillars of a SMS are: Risk identification; safety assurance (analysis and corrective action); policy and design; and safety culture.

7. Chiefs: Get your managers and supervisors on board.

   Every EMS Chief I have ever spoken to agrees that safety is a priority. They all believe that human contributions to adverse events are rarely malicious or a sign of stupidity; they believe we can learn from these mistakes, and design our systems to be resilient to human factors such as fatigue and stress. However, these beliefs don’t seem to be embedded in the organizations which they lead. Managers and supervisors are constantly cited by field medics as barriers to speaking up – in some cases, they are viewed as oppressive or threatening. Without a culture where field staff can come forward and discuss near misses and adverse events without fear of being fired or ridiculed, mum’s the word. It’s important that everyone in the organization buys into the just culture of learning and encourage those who shine a light on hazards. Without such a culture, we’ll all be in the dark.

6. Implement an anonymous reporting system (or ask your boss to implement it).

   Are you an EMS Chief? How do your staff inform your organization of adverse events and near misses? How are those reports tracked? Do you have a system in place to ensure corrective measures are implemented? Do you close the loop with the person who reported the incident so that they feel validated and are willing to report again in the future? Adverse event and near miss reports should be tracked through a safety management system to ensure nothing slips through the cracks and that your EMS operation is improved at every opportunity. It also allows you to measure the impact of safety interventions, which can support business cases needed to make further enhancements to your system. These systems are easy – you can make your own using a tool like SurveyMonkey. Keep it simple – ask two questions. “What was the near miss/adverse event?” and “What can this organization do to prevent that from happening again?” Alternatively, the EMS Chiefs of Canada supports CLIR, an online adverse event reporting tool. Check it out at http://event.clirems.org. Anyone can go to this site and report an adverse event or near miss. Anyone. Even you! Anytime. Like right now!

5. Chiefs: Get your paramedics on board.

   Do your paramedics feel comfortable speaking about calls that don’t go according to the textbook? EMS has a long history of, well, hanging each other out to dry. We blame and shame people who make human mistakes, in settings where perfection is not only unrealistic, but impossible. Aviation realized this long ago; almost every plane crash was the pilots fault, and firing them wasn’t solving anything. Instead, engineering systems that prevent human error lead to sustained safety improvements. Paramedics need to hear the message – from you, the chief of their service, and their medical director too – times are shifting. The only way to learn from unwanted situations is to talk about them, ponder them, and share them.

4. Paramedics, self report.

   Often the paramedic is the only one in the field doing the work that is hazardous. If paramedics don’t speak up, no one else will. We (practicing paramedics) see stuff that dispatchers, managers and medical directors don’t; we carry the burden of poorly designed systems on our shoulders, deflecting bad policies and equipment designs until one slips through. Then, we pretend we didn’t see it. When something goes wrong, or almost wrong, paramedics have to let their boss know. An e-mail, a phone call, an informal chat; anything will do to start shifting the culture. We should all feel free to discuss adverse events and near misses without fear of retribution. If you made a mistake, chances are it has been made before by others, and will be made again by someone else. Nothing should be taboo.

3. Consider root causes when investigating events.

   So now that you have a SMS in place, and your entire organization exhibits the behaviours of a learning culture, we can start to design better systems. When an adverse event occurs, don’t ask what should have happened; ask what did happen that led to the error occurring. Understanding root causes of error have lead to improvements such as colour coded medications, reading back call addresses to ensure accuracy, placing bougie intubation devices under the head of the stretcher so they are always available, and creating checklists to ensure procedures aren’t missed. This doesn’t have to be complicated – the tourniquet is an excellent example of how a root cause analysis led to engineering changes to improve safety. Tourniquets used to be rubber latex, the colour of pale skin. Nurses, phlebotomists and paramedics occasionally left these on long after IVs were started or blood was drawn. The solution was to make them blue, or purple, or some other colour that was bright and stood out against skin to visually remind people to remove the tourniquet. One thing is for sure: You can send out memos all day long, but memos don’t address human factors such as stress, workload and fatigue.

2. Implement meaningful changes.

   It’s one thing to cover your ass…ociation. Risk management is important, and part of your job. After all, the mortgage must be paid. But ask yourself if your “fix” is actually fixing anything in real life, or just adding to the thickness of your P&P manual. Creative, innovative solutions are often easy to come across if you open your mind to new ideas. Sometimes, we can steal great ideas from other healthcare or high-risk industries. You don’t have to reinvent the wheel.

1. Praise people who share their experiences. (Tag line: “Self reporting error is awesome!)

   No one enters the health-care industry to hurt people. I have yet to meet a paramedic who doesn’t take pride in their work. None of us like screwing up. But we are all human, and we all make mistakes. Sometimes system elements contribute to those mistakes, and sometimes environmental elements contribute to those mistakes. Sometimes, we just screw up all on our own. And that hurts. When people come forward and identify areas of concern, praise them for their courage and show them that you are going to act on their information. Because if someone makes a mistake, it’s only a matter of time before I make it. And like every paramedic out there, I hate making mistakes.