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Why errors happen during lifesaving EMS interventions

A teenager’s death after a misplaced and unrecognized failed intubation is a tragic reminder of how and why error can occur in EMS


Drew Hughes’ middle school photo

Courtesy David Hughes

By Bradley Dean

Following the release of two pivotal landmark reports by the Institute of Medicine Committee on Quality of Health Care in America in 1999 and 2001, patient safety has become a priority issue and area of focus, but only recently has EMS joined the movement [1,2].

While some demonstrated improvement has occurred, there is still much room for improvement in delivering safe, high-quality health care within the realm of EMS. In late 2015 another report, “Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after ‘To Err Is Human” called for the establishment of a total systems approach and a culture of safety [3].

In EMS, we are forced to make critical decisions during tough clinical moments, which is difficult when there are different people and personalities involved in the care of a seriously ill or injured patient. As providers, we make decisions based on clinical judgement, personal experience and the immediate information available.

In the early stages of patient care, accurate information is limited and to some extent our decisions are educated guesses. Better quality background information reduces the degree of guesswork and increases the quality of care through open communication among all providers involved.

Error reduction strategies
We all make mistakes and we must recognize that human error is inevitable. We must also realize what we can do to reduce those errors in critical situations.

1. Recognize predictable human factors
James Reason, a psychologist human performance expert, describes numerous human factors that predictably lead to errors in complex systems [4]. When people are fatigued or stressed, memory, vigilance and attention to detail often decrease, leading to increased possibility for errors.

Providers who are required to perform multiple complex cognitive tasks simultaneously are likely to experience errors in techniques or skill performance, such as calculation of pediatric medication dosages and maintaining an airway.

2. Designate a team leader
The emphasis in ACLS and PALS on the identification of a team leader is crucial to optimizing chances for survival of critically ill patients. The team leader distributes the cognitive load as reasonable assignments to responsible providers.

A dedicated team leader who briefs the team and allows the members to introduce themselves to each other opens communication streams and allows input to decision making. The team leader then should stand back, maintain situational awareness, observe the team, watch and listen, remain conscious of the ticking clock, allow the team members to perform their individual specialty roles while ensuring that care is swift and targeted.

3. Team familiarity
Crew familiarity is another aspect that causes hesitation in communication and impairs appropriate resource management. EMS is a high-risk setting because of the unpredictable patient needs, and the wide range of skills required to manage individual patients.

With critically ill or injured patients, whether field response, or critical care transport, team familiarity is important to improve communication and clinical care. Field care of patients should not be comparable to a pick-up basketball game or a flag football game where individual teammates have a shared understanding of the goals of the game, they know their individual roles and responsibilities, but they may not be acquainted or familiar with each other [5].

Crew resource management for critical interventions
In the case of an improperly placed endotracheal tube that goes unrecognized, the rapid deterioration of the patient should direct at least one provider to recheck the tube, but let’s take a moment to look at the management of the situation.

During the process of rapid sequence induction, there are generally multiple providers involved in managing the patient. Someone must clearly be in charge of the overall management of the patient, while others are in charge of their respective tasks: ventilation and pre-oxygenation; medication preparation and administration; preparation of intubation equipment; patient monitoring and recording. While all of these tasks are being performed simultaneously, yet independently to reduce the cognitive load, the crew must work together to communicate and make informed decisions so each person is aware of the entire clinical picture.

The death of a patient from an improperly placed endotracheal tube occurs when provider attention is diverted and inadvertently skips steps and priorities. This can occur because of a piece of equipment is not working as expected, medication calculations, different medication packaging, such as calling a medication by brand name, though it is packaged under a generic name. Perhaps you are suddenly working on an ambulance that is not situated the same as the one you are normally working on, changing your environmental awareness.

Do it for Drew
Drew Hughes died of an anoxic brain injury as the result of an unrecognized improperly placed endotracheal tube after being re-intubated during a hospital-to-hospital transfer. There were likely some crew resource management and patient safety issues.

The on-duty EMS crew at the transferring facility was in the process of completing another transfer and not immediately available. The crew assembled to initiate the transport by the transferring facility was not familiar with one another and did not normally work together.

The respiratory therapist assigned to the transfer was the least experienced one available and not the one who initially intubated Drew who was familiar with his case. Both the respiratory therapist and nurse assigned to the transfer were unfamiliar with the ambulance and specifics of EMS operations.

During transport, the paramedics did a crew change, introducing additional personnel unfamiliar with the nurse and respiratory therapist, to complete the transport. The new paramedic in charge of Drew’s care did not have any communication with the paramedic she was replacing and did not receive a full patient report, from the remaining crew, prior to continuation of the transport.

This unfortunate chain of events created opportunities rather than reducing the risk for predictable human errors, lacked a clear team leader to see the big picture to distribute the load and formed teams with unfamiliar crew configurations, as well as normal operations.

About the author
Bradley Dean is the Battalion Chief over the Training Division for Rowan County Emergency Services in Salisbury, N.C. He also serves as the Paramedic Program Director for Rowan-Cabarrus Community College. Dean began his career as a volunteer with the Thomasville (N.C.) Rescue Squad and in 1996 went to work for Davidson County EMS in Lexington, N.C. where he still works part-time. He and several colleagues host the Tuesday EMS Tidbits podcast and Facebook group to share EMS ideas and tips.

1. Institute of Medicine, Committee on Quality of Health Care in America. To Err Is Human: Building a safer Health System. Kohn LT, Corrigan JM, Donaldson MS, eds. Washington, DC: National Academies Press; 2000.

2. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

3. National Patient Safety Foundation. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. National Patient Safety Foundation, Boston, MA; 2015.

4. Reason JT. Human Error. New York, NY: Cambridge University Press; 1990.

5. Paterson, PD, et al. How familiar are clinician teammates in the emergency department? Emerg Med J 2015;32:258-262.