How EMS can improve care with newest patient safety recommendations

'Free from Harm,' a new report from the National Patient Safety Foundation makes follow-up recommendations to the IOM 'To Err is Human' report

The National Patient Safety Foundation (NPSF) published a follow-up report to the now famous Institute of Medicine’s "To Err Is Human." The new report, "Free from Harm", calls attention to the patient safety lessons learned over the past decade and a half, as well as reminding health care providers that many of the same issues initially spotlighted still remain.

Although EMS is not specifically mentioned in the report, given the increased focus that the care continuum receives, it stands to reason that EMS is clumped with other outpatient providers. Beyond the occasional special section in journals like Prehopsital Emergency Care, the EMS industry isn’t known for patient safety research, but that tone is changing. An increased focus on the safety of providers seems to be causing a paradigm shift that is allowing EMS to look at patient safety just as closely.

The "Free from Harm" report makes eight recommendations which can be tied to EMS. Some are more applicable than others, but all have some relevance. Here are the recommendations and how they connect to EMS:

Recommendation 1: Ensure that leaders establish and sustain a culture of safety
The recently dissolved Health and Safety Commission of the United Kingdom wrote, "organizations with a positive safety culture are characterized by communications focused on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures." But changing the culture within any organization is difficult; and doing so in an organization where most employees are siloed into two-person teams is even harder. That’s why culture is the first recommendation, because leaders must ensure that it is the primary goal since "improved culture is not the means to the end, but an end itself.”

In 2013 American College of Emergency Physicians (ACEP) released "Strategy for a National EMS Culture of Safety," which recognized that EMS poses a safety threat to not only its own personnel, but also patients and bystanders. The strategy had six core elements for advancing the culture of safety in EMS, many of which mirror the "Free from Harm" recommendations.

ACEP and National Association of EMS Physicians NAEMSP recently released a joint policy statement, further arguing that "it is the EMS physician’s role to develop and support a culture of safety in EMS systems." However since many leaders within EMS are not physicians, its stands to reason that it is the EMS leader’s role to develop and support a culture of safety in EMS systems.

Recommendation 2: Create centralized and coordinated oversight of patient safety
The first part of this recommendation is geared towards government officials and policy makers. Much like the Field EMS Bill advocates for a centralized authority over EMS, the authors hope to one day see patient safety housed within a single federal agency. In the meantime it is up to individual organizations and industries to create, or participate in, a centralized system.

The second part of this recommendation focuses on the lack of coordination within and across industry lines. Within EMS there is no central repository for adverse event reporting. Although states like Pennsylvania and organizations such as the Center for Leadership, Innovation and Research in EMS have taken the initiative to create voluntary reporting systems, they remain extremely underutilized. Until the industry is able to implement a culture that expects, appreciates and validates event reporting, it stands to reason that no reporting system, regardless of how effectively it is designed, will be used appropriately.

Recommendation 3: Create a common set of safety metrics that reflect meaningful outcomes
The authors of the report recognize that "measurement is foundational to advancing improvement," but they also admit that measuring can have unintended consequences if the data is used in an inappropriate fashion. EMS is already making progress on this recommendation via EMS Compass which helps "EMS systems measure and improve the quality of care at the local, regional and national levels" by developing relevant performance measures.

Organizations can choose whether or not to follow the EMS Compass measures, along with other standards of care that have been previously advocated by many within the industry. But there are no hard and fast rules that organizations have to adopt certain practices or metrics. This means there will continue to be significant variation across the country regarding the implementation of a standard set of metrics. Although many would like to argue that if you’ve seen one EMS system, you’ve seen one EMS system, the reality is that most variation in how care is provided only causes more harm than good.   

Recommendation 4: Increase funding for research in patient safety and implementation science
The EMS industry must decide to prioritize and therefore fund patient safety research since waiting for money to come from national and state level governments isn’t a sustainable option. Advocacy groups, professional organizations and the individuals that make up the upper echelon of EMS leadership must embrace the idea of research in EMS in general and then further recognize that patient safety is top priority.

Programs like the EMS Safety/Quality Champions Fellowship and the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship can be reinstated, or if that is not possible, the Center for Patient Safety can be embraced by the industry, and therefore allowed to play a larger role in training and educating EMS leadership on the fundamentals of patient safety.

Recommendation 5: Address safety across the entire care continuum
EMS fits perfectly into this recommendation. By definition, the industry crosses the care continuum. But the epidemiology of patient safety incidents within EMS is largely unknown. Besides a handful of studies that have looked at specific organizations, reporting systems or clinical processes, knowledge on the state of patient safety is nonexistent. But the only way to increase our understanding of what patient safety looks like is via an increase in research and improved methods of data collection (bringing us back to recommendations 2-4).

Because the unique position of EMS within the health care industry, prehospital providers are often the first to witness patient safety incidents that were the result of poor coordination between other organizations. Some mobile integrated health care and community paramedicine programs are targeting these gaps in coordination in very successful ways, reducing costs, improving quality and decreasing the need for access because patients’ conditions are well managed.

Recommendation 6: Support the health care workforce
Per another NPSF report "workplace safety is … inextricably linked to patient safety. Unless caregivers are given the protection, respect and support they need, they are more likely to make errors, fail to follow safe practices and not work well in teams."

All EMS providers should have a minimal understanding of the importance of quality and patient safety. They should be well-versed on the requisite vocabulary, and comfortable identifying and reporting adverse events when they occur. Leadership can’t be on every call, so employees must feel empowered enough to speak up when something doesn’t go according to plan.

Workplace safety is an immense issue within EMS, and it should be just as important as patient safety. A recent publication in BMJ Open evaluated the types of injuries and near misses that firefighters received while responding to medical calls, only providing further proof that EMS providers face hazards not seen by the majority of the workforce.

Recommendation 7: Partner with patients and families for the safest care
EMS providers are often forced to make clinical decisions in less than ideal environments. This means that it is much harder to incorporate the wishes of the patient into the delivery of care; such that even simple decisions like which hospital the patient should be transported to can become a representation of patient safety versus patient satisfaction.

Knowing how to communicate effectively with patients is vital. As is incorporating patients into the decision making process that occurs well before 911 is dialed. Patients are a stakeholder within EMS, and they should be treated as such. This means including them on the board of directors, providing them timely access to their personal medical records, and engaging them in any investigation should an adverse event occur.

Recommendation 8: Ensure that technology is safe and optimized to improve patient safety
 is a vital part of the care delivered within EMS. But occasionally technology fails and creates an issue that would not have otherwise been present. It is the responsibility of EMS organizations and their leadership to take steps to prevent those failures.

Additionally, technology provides an opportunity to share information across organizations, creating a more seamless transition of care. Whether it involves transmitting an EKG en route or participating in a health information exchange with other local providers, technology has the ability to significantly improve patient safety and experience via increased coordination.

EMS must join the discussion
These recommendations speak to the direction patient safety is headed. Any EMS provider or professional organization is free to endorse the "Free from Harm" report. As with any new concept, early adopters will have the chance to shape the conversation and decisions being made in a prospective manner, rather than reacting once the tides have shifted.


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