The EVENT System Offers Insight Into Our Errors
The first patient-safety error report from the EVENT system, released in late 2012, provides an initial bit of what hopefully will be much insight into errors committed by EMS providers.
EVENT stands for the EMS Voluntary Event Notification Tool. An effort of the Minnesota-based Center for Leadership, Innovation and Research in EMS (CLIR), it lets providers anonymously report incidents that threaten patient safety. As data is amassed, it will help inform policies, procedures and training to reduce the likelihood of future events.
Over a reporting period of July 2010–June 2012, the EVENT system amassed 21 patient-safety incidents from the U.S. and 6 from Canada. That’s not a lot, but according to the report’s authors, “We feel this is a good start for a relatively new effort in our profession.” They encourage providers to contribute reports and help build their body of data.
Most of the reports came from North Carolina. That of course doesn’t suggest providers in that state commit more errors; only that more participated in EVENT during the period in question.
Of the events, three-quarters involved medical treatment, and most of those were medication errors. Other event types included procedure/operation events, human errors/errors in clinical judgment, and one event related to training.
Alarmingly, four patients experienced harm as a result of their events, and two died.
The report also includes provider opinions on what caused their events. Multiple medication errors were attributed to similar containers, adjacent storage and failure to double-check/observe the rights of drug administration.
Besides being added to aggregate data, individual event reports are shared, with no identifying information, with their state EMS offices. Further EVENT aggregate reports will be forthcoming. To participate in the system and contribute to a more accurate big picture, see www.emseventreport.com.
