Creating a Culture of Safety

EMS is dangerous to a lot of people in a lot of ways. Those who provide it are 2½ times more likely to be killed on the job than the average American worker.¹ Those who receive it may be exposed to medical errors, accidental trauma and other adverse events. Even the general public can be threatened through our high rate of ambulance crashes.

We all know this, and it’s led to valiant efforts across countless departments to ameliorate danger and promote safety. Protocols preach it, and everything from gloves to powered cots to driver-feedback systems and a million other things result from this quest. To be sure, these measures have improved things, and we’re safer than we used to be. But just as surely, things can still get better.

Part of what’s missing is a thoroughgoing unity of approach that links disparate agencies and practices into a common vision and collective effort. That’s where the National EMS Culture of Safety Strategy comes in. A three-year effort prompted by NHTSA and spearheaded by ACEP, it’s brought together leaders from all the top EMS and fire groups to develop a blueprint for that elusive encompassing “culture” of safety.

“The spirit of the project was not to create another whole federal bureaucracy or some federal imperative, but for EMS stakeholders to come together and become more cohesive about some of the great work that’s already being done,” says project chair Sabina Braithwaite, MD, MPH, FACEP, EMS medical director in Wichita-Sedgwick County, KS. “We want to develop a more cohesive approach toward a common vision, and also to really create capacity to share things people are doing. Sometimes great things are being done in small islands, but if nobody knows about them, it’s hard to replicate them. It’s a shame for people to have to reinvent the wheel.”

Sparing that reinvention poses a challenge to be sure. The concept of safety permeates so many aspects of EMS, and we don’t have full pictures of what poses harm and risk. Reporting of accidents and adverse events is spotty, definitions are inconsistent, information isn’t shared, and many providers simply resign to risk as part of their jobs. That all has to change.

“What we’re trying to create,” says Braithwaite, “is an environment where the culture of even the smallest organization is oriented to safety all the way through.”

Key Elements

The project’s current draft (version 3.1, available at www.emscultureofsafety.org) bases the strategy on six key elements.

1. Just Culture—Used in industries like aviation and other areas of healthcare, Just Culture encourages the reporting of mistakes and a new approach to dealing with them. The idea is that most mistakes are system-based, and reporting errors and near-misses allows fixing of their precursors (e.g., similar meds located adjacently lead to the wrong one being given; an ambulance narrowly escapes a crash because a known lead-foot was driving too fast). Conversely, punishing mistakes can discourage their reporting and let risks continue unaddressed.

Just Culture identifies three degrees of behavior warranting distinct responses: Human error should be consoled; risky behavior should be counseled; and only reckless behavior should be punished.

2. Coordinated support and resources—As a single instrument to collate a nation’s safety efforts, a proposed EMS Safety Resource Center could reach out to providers, share resources and best practices, and help coordinate safety activities and measure progress.

3. A responder and patient safety data system—Data pertaining to EMS safety is currently ill-defined, inconsistently collected and scattered in location. A unified safety-data system, national in breadth and broadly accessible, could help us understand the frequency, scope and nature of injuries to providers and their patients.

4. Evolution of EMS education—Safety must flow from leaders and educators on down and be integrally woven into every facet of EMS education. This would encompass early identification of job candidates prone to risky behavior, developing critical-thinking skills to inform clinical judgment, transitioning new employees with good safety practices, and reinforcing the culture at all opportunities.

5. Promulgation of safety standards—As part of its mission, the EMS Safety Resource Center would promote evidence-based standards to enhance both responder and patient safety. To get started, it would collaborate with experts on a prioritized list of standards to be addressed or created by various organizations. Top priority would go to those that support safety not only operationally and technically, but culturally as well. These may include areas such as physical fitness; shifts/fatigue; categorizing and reporting violence; escaping and preventing violence; medical and patient-moving equipment; ambulance design; dispatch; driving; PPE and more.

6. Incident reporting and investigation—With standardization and comprehensive reporting of EMS safety data, appropriate bodies like the NTSB can begin to investigate serious vehicle crashes and other high-profile risks. The Safety Resource Center would determine what data is needed and available, including collecting existing state data. Reporting should be mandated, with a provision for anonymity and legal support against data’s use in claims against reporting organizations.

How to Get There

To get from here to there, Culture of Safety project leaders offer handy to-do lists. These aren’t all it will take, of course, but they represent concrete next steps for all system participants, from individual providers and agencies to organizations, educators, state and local governments, vendors and even the media.

The final version of the National Culture of Safety Strategy is due in September 2013. Whether its biggest goals can be attained, we’ll see. Bright EMS minds have produced many fine documents that have failed to yield the intended results, but also some that have.

Safety, though, isn’t all or nothing—there’s benefit to incremental progress. It’s a long process, Braithwaite says, but one with intermediate wins—each crash prevented, medication error averted and incident reported and examined and learned from represents a victory for awareness and a contribution to the culture.

That’s reason enough to start today.

Culture of Safety Strategy To-Do Lists

Individual Practitioners

• Be open to any team members raising safety concerns, regardless of their tenure and rank;

• Be willing to report errors;

• Collaborate with management;

• Seek opportunities to expand knowledge base on culture, patient safety, latest info and research on clinical safety, responder safety, personal protective equipment, etc., and be willing to bring these to the attention of management;

• Ask medical director what can be done to improve safety for responders, patients and the public;

• Report safety hazards;

• Perform safety checks, vehicle inventory and safety inspections conscientiously;

• Be willing to speak up when a partner or other responder seems fatigued or under mental or emotional stress;

• Maintain personal physical well-being, get enough sleep and exercise;

• Take advantage of CE opportunities to learn about your own physical and mental wellness.

EMS Provider Agencies

• Establish a better understanding of safety culture in EMS nationwide by encouraging local EMS agencies to measure their safety culture using reliable and valid tools (e.g., the EMSSAQ). This may be accomplished individually by the agency or by taking part in a national effort (e.g., EMSARN.org);

• While educators can do some of this type of screening, emphasize the importance of developing pre-employment screening and evaluation tools based on solid research (for example, potential workers with a history of speeding violations or crashes will be more at risk than others for speeding or crashing the ambulance, and potential workers with previous back injuries will be more at risk for future back injuries). Such tools would not necessarily need to prohibit employment but could be used to track new employees into specialized mini-courses. However, screening such as this is not the purview of educators. Instead, employers must recognize their responsibility in articulating standards so that potential employees will know if they might be excluded from employment before undertaking a long educational program;

• Adopt values of Just Culture or choose another model to review and adopt;

• Find, develop or provide education and safety information (such as NAEMT’s EMS Safety Course) to membership;

• Support or participate in research.

EMS Physicians & Medical Directors

• Work to ensure that local EMS services are addressing EMS safety through current training and updated operational procedures;

• Continue to ensure EMS safety is a priority in local EMS services through training and operational procedures that are developed based on evidence-based research and national standards.

Associations

• Adopt values of Just Culture or choose another model to review and adopt;

• Find, develop or provide education and safety information to membership;

• Support research; fund it, share results, issue press releases, publish on it, list research as a top priority of the organization;

• Make safety part of the association’s mission;

• Support the (yet to be developed) resource center. Share costs, share documents, etc.;

• Raise the profile of safety wherever possible throughout the organization’s initiatives;

• Include safety presentations at annual meetings and conferences;

• Issue a proclamation supporting the Strategy or the concept of a culture of safety;

• Partner with non-endemic organizations to bring outside safety ideas into the mix;

• Make sure members have access to the Strategy document and are aware of it;

• Find best practices, encourage members to share their safety policies and safety training materials;

• Survey membership about safety practices and share the results;

• Advocate for dedicated funding for research and mechanisms to distribute that funding for EMS safety research (both patient safety and provider/practitioner safety);

• Consider an annual award for best practices in EMS safety.

Educators

• Encourage development of curricula that introduce safety culture and safety practices related to patient safety, occupational safety and public safety;

• Future editions discuss safety;

• Education for leaders;

• ID high-risk individuals in class;

• Focus on education that builds clinical judgment beyond technical skills;

• FTEP.

Standard-Setting Bodies (e.g., NFPA, ASTM, CAAS)

• Review accreditation to look for opportunities to include safety;

• Consider standards related to wellness, annual fitness test;

• Review research presented by TRB;

• Evaluate benefits of mandating formal EMD training and procedures in dispatch centers.

Local Government Stakeholders

• When putting ambulance services out to bid, incorporate safety as a high-profile consideration in RFPs, to include reporting/monitoring;

• Ensure contractor adheres to a responsible UHU to reduce the likelihood of fatigue and other risks that may lead to injury or error;

• Require that PSAPs have EMD;

• Regional EMS councils should require continuing education, make changes to protocols to communication standards, make accreditation and licensure requirements, adopt the practices of Just Culture.

State Government Stakeholders

• Introduce or strengthen legislation making it a felony to assault EMS responders;

• Support research through the adoption of NEMSIS-compliant patient care reporting systems, state EMS vehicle-involved collision reporting, and promotion of voluntary anonymous reporting (e.g., through EVENT);

• Modify state EMS laws or rules to incorporate safety-related provisions into local EMS agency and personnel requirements;

• Include safety-related messages in all correspondence and documents sent to local EMS agency officials and personnel;

• Adopt values of Just Culture or choose another model to review and adopt in the state EMS office;

• Find, develop or provide education and safety information to EMS personnel and local EMS agency officials;

• Make safety part of the state EMS office mission;

• Support and utilize EMSSRC;

• Raise profile of safety wherever possible throughout the organization’s initiatives;

• Include safety presentations at annual meetings and conferences;

• Issue a proclamation supporting the Strategy or the concept of a culture of safety;

• Partner with non-endemic statewide or local organizations to bring outside safety ideas into the mix;

• Find best practices, encourage EMS personnel and local EMS agency officials to share their safety policies and safety training materials;

• Survey EMS personnel and local EMS agency officials about safety practices and share the results;

• Ensure that EMS personnel and local EMS agency officials have access to the Strategy document and are aware of it.

Researchers

• Establish a better understanding of safety culture in EMS nationwide by encouraging local EMS agencies to measure their safety culture using reliable and valid tools (e.g., the EMSSAQ). This may be accomplished individually by the agency or by taking part in a national effort (e.g., EMSARN.org);

• There is a lack of reliable and valid tools to measure safety in EMS. Continue to develop and test measurement tools to quantify the magnitude of problems in EMS responder safety, patient safety and safety of the public;

• Develop research to define fatigue mitigation and fatigue modeling for ground service personnel as is done with air medical teams. Develop risk assessment tools to measure fatigue;

• Build confidence in measurement before moving to research on interventions to impact behavior and practices at the front line;

• Examine the evidence of how EMS workers get injured and the reasons EMS workers leave the profession, and then develop and evaluate evidence-based interventions to prevent their injuries and improve their health.

EMS Vendors and Manufacturers

• Engineer fail-safe devices and mechanisms to increase both provider safety and patient safety—i.e., features that make it difficult to be unsafe;

• Directly engage end users (providers) in product development and marketing;

• Focus on how engaging end users/customers makes EMS safer in product design and development phases;

• Participate in discussions with providers regarding their culture of safety;

• Search throughout the world to find solutions that could be brought to the U.S.;

• Openly report on product testing and evaluation, initially and periodically as necessary;

• Release conflict of interest statements while attending all conferences, seminars or educational functions (other than the obvious);

• Identify “off-label” uses of equipment and provide statements directly addressing the potential impacts to provider, patient and public safety;

• Consider a product failure notification network for equipment and product failure not covered under existing law;

• Adopt cost/safety model in the development of products (i.e., safety at what cost; options for those who can’t afford).

EMS Media & Conferences

• Conduct surveys and polls and report on the results;

• Look for opportunities to promote and elevate safety, single subject articles and workshops;

• Speaker guidelines at EMS conferences can ask speakers to integrate concepts of safety into their presentations as appropriate to the topic;

• Assign articles based on concepts and topics that come from the Culture of Safety document;

• Change author guidelines to consider safety issues in any topic;

• Keep safety a hot topic in the community by covering it regularly and in a variety of ways.

Misc. or EMSSRC

• Sponsor an interdisciplinary national conference on safety.

Reference

1. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med. 2002 Dec; 40(6): 625–32.