When a mistake happens in health care, the traditional way of handling the situation is to determine who caused the harm and then either re-train or punish the person responsible. But there’s been a growing movement away from blaming the individual and toward looking for ways to improve the system to prevent mistakes and other adverse events from occurring in the first place.
With that in mind, American Medical Response (AMR) is getting ready to launch a major patient safety initiative that will focus on system fixes, says Scott Bourn, vice president of clinical practices and research at AMR’s Denver headquarters.
“Over the past 10 years or so, health care has come to understand that adverse events are inevitable. It’s a statistical guarantee that things will go wrong,” he says. “For a long time, people struggled with that idea. They thought, if we just try really hard, nothing will go wrong.”
It hasn’t yet been decided what precisely the AMR program will encompass. But the first step will be an online training program for paramedics and EMTs who staff the company’s 4,500 ambulances to educate them about adverse events, and to begin to get staff to think about a systems approach to prevention. That should start this winter, according to Bourn.
“We need them to understand it’s a cultural shift away from automatically punishing people, and instead to drill down and understand what caused [the incident] and to fix it from a systems perspective,” he says.
Let’s say a paramedic administers the wrong medication. Yes, that individual made a mistake. But how to prevent it from happening again? Perhaps the solution lies in more clearly labeling the bottles or color-coding them, Bourn says.
Which specific areas of patient care will be targeted is also still to be decided. While much research has been done on adverse events in hospitals, Bourn says there’s much less information on when and where adverse events occur in EMS.
But the groundwork is being laid. All AMR locations are transitioning to the same electronic patient care platform, which will help in collecting and analyzing millions of patient records collected annually. Research in hospitals suggests that adverse events often occur when patients are being transferred from one care team to another; it remains to be seen if the same will be found in the prehospital environment, according to Bourn.
As for identifying adverse events—which can include outright errors and injuries caused by medical management—he expects the information to include both events reported by staff and those that can be discerned via data analysis using certain “triggers.” For example, an electronic health record that indicates a patient was given Narcan might indicate a medication error. He’s hoping to have a better handle on the sources of adverse events by the latter half of 2012.
To develop the specifics of the plan, Bourn says he’ll work with AMR’s clinical leaders and the Institute for Healthcare Improvement, a nonprofit agency based in Cambridge, Mass., that offers quality improvement programs.
“There needs to be a paradigm shift away from the idea that adverse events are someone’s fault and we need to punish or train them, to realizing that adverse events are a systems issue and the best way to deal with it is to talk about it,” Bourn says. “Let’s not hide it. Let’s bring it to the fore, figure out what happened, why it happened and if we can prevent it from happening again and build that into the system.”
D.C. Grapples With Twitter Use
The District of Columbia’s Fire and EMS Department temporarily suspended its Twitter feed in September after questions arose about “incorrect or inappropriate” information being published on it.
D.C. Fire and EMS’s Twitter account is hugely popular, garnering more than 10,000 followers in the news media and the public who turn to it for real-time updates on emergency incidents ranging from traffic crashes to fatal shootings.
Communications Director Lon Walls would not elaborate on specific instances of inappropriate “tweets” but suggested the department needs to stay away from posting information about shootings (a police matter) and stick to incidents specifically involving EMS and fire.
“I’m a strong proponent of making sure information is accurate … and folks really staying in their lanes when it comes to certain information,” he says. “Twitter is important because it’s real time, but we have the potential to sacrifice accuracy in trying to be fast. And we’re really concerned about that.”
The temporary halt to the Twitter account, which was prompted in part when the communications officer who was handling it went on vacation, Walls says, was covered in the D.C. papers.
The tweets typically relayed information passed over fire department scanners about ongoing incidents, according to news reports. “The primary concern is public safety,” Walls says. Tweeting about ongoing incidents could compromise a police investigation, or prompt a flood of calls to their department or to the police department with officials unable to provide accurate information because they don’t know it yet, he adds.
“You could tweet something that is inaccurate, and it spreads like wildfire, and how do you undo that?” Walls says.
Today, the Twitter account is being updated 10 or more times daily, but only for fire and EMS-related incidents.
And while other fire and EMS departments are experimenting with Facebook pages that enable members of the community to post comments on the Facebook “wall” about the service they receive, D.C. Fire and EMS has opted to have only a Facebook “fan page,” which isn’t interactive. “You don’t have to worry about commentary you don’t want on your wall,” Walls says. “I’m not a fan of that. I’m really not. There is a lot of negative stuff out there, and there is the potential for problems. I don’t feel comfortable with something like that.”
EMSA to Continue Providing EMS to Oklahoma City
The Oklahoma City Council decided in October to continue the city’s participation in the EMSA (Emergency Medical Services Authority) Trust, which provides EMS to Oklahoma City, Tulsa and other smaller cities in the region.
Every five years, the agreement comes up for review. Both the Tulsa Fire Department and the Oklahoma City Fire Department made a pitch to take over ambulance transport, saying they could provide EMS at less cost.
The Trust can only be dissolved if all parties agree. Since Tulsa had already announced its decision to stick with EMSA, Oklahoma City had to follow suit. At least one city council member expressed interest in changing that agreement to make it easier for Oklahoma City to opt out in five years, according to the Oklahoman.
Man Goes by Ambulance to Son’s Baseball Game
For the past year, Jim Orr of Washougal, Wash., has been in and out of the hospital battling melanoma. During a recent trip by ambulance, he mentioned to American Medical Response EMT Della Bornman and paramedic Dan Carlton that he was going to miss his son’s baseball game that evening. Soon, the two had put a plan into place to get Orr to the game—during which his son scored a home run. “The emotions and feelings I took away from this incident were overwhelming,” Carlton told KGW-Portland.
