Turning Mistakes Into Learning

In 1999, a landmark report from the Institute of Medicine, To Err is Human, estimated that at least 44,000 (and perhaps as many as 98,000) Americans die in hospitals each year as a result of medical errors, and that hospital patient-safety incidents account for $6 billion a year in extra costs in the U.S.

That should make EMS leaders wonder about mistakes in their own systems that may harm patients and increase costs.

In a 2002 Prehospital Emergency Care article, authors led by Robert O’Connor, MD, MPH, wrote a consensus statement that represented the views of several respected medical directors regarding the national state of EMS safety. The group identified common EMS errors and concluded that standard operating procedures to prevent and recover from errors in the field were “in their infancy.” Shortly thereafter, researchers surveyed 283 EMS providers attending a North Carolina EMS conference and found 44% of them had committed one or more errors during the previous year. Only half of those errors were reported to a supervisor or medical director.

In 2008, the Richmond Ambulance Authority’s operational medical director, Joseph P. Ornato, MD—an instrument-rated pilot who had firsthand experience with the high level of safety achieved in the aviation field—instigated a successful error self-reporting program patterned after the Aviation Safety Reporting System (ASRS) developed by NASA. The NASA system was designed to detect all near-misses and translate lessons learned into operational process changes, rather than blaming individuals for human errors.

A successful self-reporting system requires high degrees of trust and confidence on all sides. Management must trust that providers are highly trained and will always do their best for their patients; staff must trust that a single first-time error or accidental oversight will result in learning and not termination. Emphasizing the tenet of complete trust, RAA has instigated a successful self-reporting program we consider a major pillar in our culture of safety and delivery of world-class EMS.

In the words of RAA’s own self-reporting standard operational guideline (SOG), “The purpose of self-reporting is a way to tell management when something goes out of the ordinary or [becomes] clinically unacceptable.” These could also be called near-misses. Examples include medication errors, overlooking important clinical procedures, driving infractions, etc.

RAA and its medical director acknowledge that self-reporting is nondisciplinary in nature—if a mistake happens, it is considered part of the learning process. That said, RAA’s self-reporting procedure only applies when a crew member promptly notifies RAA of their potential error. A report should be completed immediately after the apparent violation has been discovered and before RAA management learns of it by other means. There is a healthy expectation that reporting immediately after an incident can lead to learning, but making the same mistake more than once is not part of the learning process—it is a pattern and may ultimately be addressed via other methods that may include disciplinary action. This rarely occurs, as the lessons RAA identifies quickly become lessons learned.

The Process

When a staff member needs to self-report, they first must notify the chief clinical officer. They must then produce an incident report before the end of the shift that includes:

• A brief description of the apparent violation, as well as how and when it was discovered;
• Verification that any noncompliance with RAA policies or procedures ceased after the error was identified;
• A brief description of the actions taken immediately upon discovery of the apparent violation, what was done to terminate the conduct that resulted in it, and the person responsible for taking the immediate action.

Once the necessary notifications and reports are complete, the RAA management team initiates an immediate evaluation to determine if there are any systemic problems and describe corrective steps to prevent any violation from recurring. As a follow-up, a manager is appointed to conduct a root cause analysis (RCA) investigation in order to prepare and present a comprehensive solution. The RCA itself identifies to RAA’s OMD and chief clinical officer:

• Specific RAA protocols/procedures that may have been violated;
• The apparent violation, as well as how and when it was detected;
• Immediate action taken to terminate the conduct that resulted in the violation, including when it was taken and who was responsible;
• Whether the apparent violation was inadvertent;
• Evidence that demonstrates the seriousness of the violation and the RAA analysis of that evidence;
• A detailed description of proposed fixes, outlining planned corrective steps along with responsibilities for implementing further learning and change.
• A timetable for completing the fix.

The detailed RCA, learning and outcomes are further analyzed by RAA’s Clinical Review Committee, which is chaired by the medical director and includes the chief operating and clinical officers and risk and safety director. We then conduct follow-ups at 30, 60 and 90 days for both the issue and the original reporting provider to ensure the solution is implemented.

RAA has a high degree of confidence in its self-reporting system, and the honesty of the process means issues are identified, solutions determined, and the whole organization benefits from the learning.

Brian’s Story

After working as a paramedic with smaller fire departments and ambulance services, Brian was finally able to move into a bigger city. With the better part of a decade as a paramedic under his belt, he thought he was up to par when it came to clinical practices and ACLS. After graduating from the training academy and spending two months with a field training officer, he became the attendant in charge of a medic unit.

In his first week as a cleared medic, Brian responded to an unconscious person. On arrival he was told by first-responding firefighters that the patient was found not breathing. Brian saw the patient was in full cardiac arrest, and the firefighters had already started CPR and were ventilating with a BVM. Placing the patient on the monitor and AutoPulse, Brian felt like something took over—before he knew it he’d started an IV, given a round of drugs and placed an advanced airway. He felt like he was on top of the world, and as the only paramedic on scene was totally in command of a situation that was progressing very well. Brian later acknowledged that the protocols he was following were different from ones he’d used before, but he didn’t think twice before administering medications.

With the assistance of the fire crew, the patient was moved into the medic unit, where he got another three rounds of drugs on the way to the hospital. By the time Brian arrived at the ED, he felt things were still going very well. In giving his handover report, he identified that he had “a 52-year-old male last seen 15 minutes before being found pulseless and apneic. He has remained asystole on the monitor after 3 rounds of epi, 3 atropine, an amp of bicarb and 300 of amiodarone.”

When Brian articulated his treatment to the ED staff, he immediately realized he had given amiodarone when he should have given vasopressin. Brian stated in his later reporting that no one else seemed to notice; he knew what each drug did and just got them mixed up and gave one in place of the other. Contemplating the consequences of his overconfident actions, Brian walked out of the ED thinking about how he would tell his family he was going to lose his job and most likely certification.

Following the self-reporting protocol, Brian contacted the on-duty supervisor and, in a voice that conveyed something was gravely wrong, explained what took place. To Brian’s surprise, he was advised to continue his shift but that he’d have to complete an incident report and ultimately meet with the operational medical director (OMD). That happened on his next shift. Brian later told his crewmates, “I braced myself for the butt-chewing of a lifetime.”

Brian’s meeting with the OMD was conducted in a nonconfrontational, learning environment, and as he explained what took place, he was asked a question he did not expect: “What could have been done to prevent this?” The discussion and debriefing with the OMD identified that Brian should have used the five rights of patient medication administration (right patient, right drug, right dose, right route, right time) to prevent this medication error. It was also recognized that a failure in training played a key role. The outcome of Brian’s OMD intervention was neither dismissal nor suspension. To ensure learning occurred, he was asked to complete a remedial ACLS class as well as a paper on the five rights of medication administration.

Where is Brian now? He is still here, and is now a captain and field operations supervisor who recently graduated from Fitch & Associates’ Ambulance Service Manager (ASM) course. The conclusion of a self-reporting paper he wrote for that provides a fitting summary to his story: Did I learn my lesson? Will I make mistakes again knowing it won’t cost me my job? The answer is yes to both questions. I walked away from this experience knowing it’s OK to make mistakes as long as we can learn from them and work to prevent them in the future. Instead of punishment I received education and the wisdom that I am human and humans make mistakes. It’s called the “practice of medicine” for the reason of improving as EMS providers. If I had walked out of that office with a pink slip and the incident swept under the rug, no one would have ever learned from it, and that includes me.

Rob Lawrence is chief operating officer of the Richmond Ambulance Authority. He previously held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a graduate of the Royal Military Academy Sandhurst and served in the Royal Army Medical Corps. After a 22-year military career in many prehospital and evacuation leadership roles, Rob joined the National Health Service, initially as the Commissioner of Ambulance Services in the East of England. He later served with the East Anglian Ambulance Service as director of operations.

Captain Brian Hupp has been with the Richmond Ambulance Authority since 2007. During his time at RAA, Brian has held the position of paramedic, ALS field training officer and assistant field operations supervisor. He is currently a field operations supervisor with the rank of captain and works as the night shift supervisor. Brian started his career with The Mechanicsburg Division of Fire & EMS and worked for Acadian Ambulance Service as a paramedic stationed on an off-shore oil drilling installation. A recent ASM graduate, Brian is also certified as an AHA and NAEMT instructor, and is cross-trained as an EMD System Status Controller for RAA Communications.