Rural Responder: Learning from Our Mistakes

It seems you can't read a journal or attend a conference these days without the subject of safety being discussed. But what does developing a culture of safety mean for the rural EMS leader? Are there more or fewer safety-culture issues in the rural environment than in the metropolitan? How does the rural ambulance leader evaluate his service's culture and safety practices? And where does the time come from to tackle one more issue--especially when a lack of accidents today suggests we don't have a problem, right?

The rural ambulance leader could begin with a simple service self-assessment. Consider the following:

• Are there processes in place to ensure safe practices in vehicle operations? For example, are response-time measures used in a way that people feel they might be punished if they're not operating the vehicle as fast as possible? Are response distances so great that people feel they have no choice but to drive as fast as possible?

   

   

• Are tools like two-person verification, medical guideline review, online medical control or the Five Rights of Medication Administration in place to aid employees in using safe means when they give medications?
• Do employees feel safety comes first, even if it potentially delays patient care? If they don't, why? What other culture exists? What disincentives are in place? What leadership is missing?
• Do you, as the service leader, model safety culture in your words and actions?

Many EMS organizations experience what might be described as a "go" culture. A "go" culture is one in which actions and behaviors are weighed most heavily by whether they achieve a desired result, even if unsafe behaviors are necessary to do so. For example, would your personnel have different behaviors when responding to an unknown medical versus a child in cardiac arrest? Perhaps they'd answer an unknown medical by driving within normal speeds, carefully approaching the scene and thoughtfully providing care in a slow and methodical way. Perhaps they'd respond to a known child in cardiac arrest by driving as fast as possible regardless of road and weather conditions, arriving on scene and running immediately to the patient, and providing treatments and procedures as rapidly as possible, forgoing bloodborne pathogen protection procedures.

Just Culture is a methodology gaining prominence as a tool to promote "blameless" cultures of safety. Just Culture has four basic principles that are considered as the influencers that affect decisions. These are human error, negligent conduct, reckless conduct and knowing violations. These principles are used to evaluate errors as well as investigate systems and processes that might lead to them. An example of this methodology is a program launched by the FAA to deal with errors by pilots. Prior to the new program, errors reported by pilots would cause punitive disciplinary action. As a result, many errors went unreported. This prevented pilots from learning from each other and increased the likelihood that errors would be repeated. Under the new program, pilots are held harmless if they self-report. This small change has allowed a huge increase in information-sharing and the ability to research and change procedures and systems identified as problematic.

Is there a need for a methodology like Just Culture in EMS? Does your agency have unsafe practices and behaviors? Do errors and accidents go un- or underreported? A Just Culture program can lead to a better understanding of errors, more effective correction of systems and processes that lead to them, and a reduction in similar errors. None of this is possible if errors aren't reported. Another benefit is having a documented process for evaluating errors. An organization will understand how to respond to errors and thereby enhance its overall commitment to safe behaviors.

A culture of safety is not a reaction to an accident, medication error or employee injury. It's a sum of proactive behaviors that begin long before an ambulance responds to a call, a medication is drawn up or an employee is in a potentially dangerous situation. As a leader, your responsibility is to begin the conversation about your current culture, identify behaviors and processes that need to change, and model behaviors that show safety is Job No. 1 for each and every employee.

Culture of Safety Resources

• The Just Culture Community--www.justculture.org
• Five Rights of Medication Safety-- https://public-healthcare-issues.suite101.com/article.cfm/five_rights_of_medication_safety
• Develop a Culture of Safety-- www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/Develop+a+Culture+of+Safety.htm
• Promoting a Culture of Safety-- www.ahrq.gov/clinic/ptsafety/Chap40.htm

Aarron Reinert, NREMT-P, BA, is executive director for Lakes Region EMS, a rural ambulance service in Minnesota that covers a service area of 450 square miles.

Gary Wingrove is responsible for strategic affairs at Mayo Clinic Medical Transport in Rochester, MN, chairs the rural EMS issue group for the National Rural Health Association and is president of the National EMS Management Association.