Literature Review: Prehospital Patient Safety

     Meisel ZF, Hargarten S, Vernick J. Addressing prehospital patient safety using the science of injury prevention and control. Preh Emerg Care 12(4):411–16, Sep 2008.

     There is inadequate information about the scope and character of adverse events in prehospital care. However, there is ample evidence to suggest that prehospital patient safety hazards are often unique and underrecognized. The authors first summarize what is currently understood about prehospital patient safety and identify the specific aspects of EMS care that may make conventional approaches to the evaluation and improvement of patient safety more difficult. Next they introduce the concept of using injury prevention and control science to analyze prehospital adverse events and help develop EMS patient safety solutions. Injury prevention and control is a proven public health approach for the study and reduction of both intentional and unintentional injuries. It includes the use of a Haddon phase-factor matrix to identify possible interventions, especially environmental modifications, that provide automatic protection. The authors demonstrate how this method can be used as a complementary approach in efforts to prevent injuries caused by prehospital adverse medical events.

     The Institute of Medicine published a landmark article in 1999, To Err is Human: Building a Safer Health System, that described how errors in medical care compromised patient safety in healthcare environments. Emergency departments are particularly high-risk because patients are often very sick, time is short and information is limited. EMS shares these challenges, and in many ways can be worse. Studies show that about 3% of hospital patients suffer adverse events. If EMS' rate is anywhere close to that, with 16 million annual transports, the effect is quite large. And although research is still needed, we all know that much can be done to improve our patients' safety.

     The authors point out that errors of omission (e.g., failing to apply a cervical collar or check blood glucose) and commission (e.g., dosage errors, improper performance of skills such as endotracheal intubation or CPR) are not infrequent in EMS. But how much these errors contribute to adverse patient events is not known. They also make the case that we need to move away from blaming individuals for specific instances of errors and begin to look at injury control methods that instead focus on methods to prevent errors. An example is prevention of over- or underdosing by stocking only one concentration of a medication.

     These prevention strategies have worked to, for example, reduce vehicle crash injuries and needlesticks. If we are going to move forward in improving patient safety, EMS systems should be looking at these models to better protect our patients and improve our care.

     Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS agencies.

     Change is often difficult, but for Metro Atlanta Ambulance Service, it was a necessity when management realized their CQ program was no longer doing an adequate job. "We were finding we had about an 80% completion rate on documentation, and we were spending a lot of time on billing, which is where it really started," explains Metro Vice President Devan Seabaugh. "Crews weren't documenting proper insurance information, social security numbers or addresses on insurance cards, which was causing us to spend more dollars on indirect labor to get bills out the door. We started by bringing in a consultant to do a documentation training class for all of our employees, who talked about the importance of legality on the patient care report and about billing information and why it's important."

     Eventually, the company implemented a new billing program and electronic PCR software and began tracking those areas to make sure everything was being documented properly. "We did that on 100% of our billing and PCRs, and every month we sent a report card to employees telling them how they were doing," says Seabaugh. "If someone went below 90%, we brought them in, went over their errors and coached them on how to correct them. Part of the report covers compliance with our standards of care and patient care protocols, and that document becomes part of their performance evaluation every year."

     Rather than look at the revised system as intrusive, employees appreciate the feedback and counseling, says Seabaugh, which was revealed when their compliance rate went from 80% to 98%.

     "As long as they know somebody's looking at them and it will become part of their performance evaluation, they're going the extra mile to make sure they document clearly and are following protocols."

     Not only has employee morale improved, says Seabaugh, but the agency is getting its bills out the door on time, which translates to better customer service.

     —Marie Nordberg, Associate Editor