Moving Away from Punitive Measures: The Role of Patient Safety Organizations in EMS

Ed's Note: Lee Varner is a featured speaker at EMS World Expo's EMS Safety Officer Program on October 6 in New Orleans, LA. The 5-day conference runs from October 3–7. Register at EMSWorldExpo.com.

Earlier this year, a study found that medical errors were the third leading cause of death in America behind cancer and heart disease. A recent webinar from the Center for Patient Safety suggests utilizing patient safety organizations can help lower this number and eliminate preventable mistakes. The webinar covered how patient safety organizations work, what their goals are and how they can help EMS agencies.

Lee Varner, EMS project manager with the Center for Patient Safety, says patient safety is an issue generating considerable interest among EMS organizations. However, many organizations don’t know how many near misses happen or how many unsafe conditions exist within their agencies because people don’t want to share when these occurrences happen. “A patient safety organization can bridge that gap and allow us to discuss these events and become more proactive,” Varner says.

Eunice Halverson, patient safety specialist with the Center for Patient Safety, says patient safety organizations offer many resources to bridge this gap. The Center for Patient Safety is one of about 80 patient safety organizations nationwide, Halverson says, and these organizations focus on helping agencies learn from mistakes and provide protection for these agencies.

To accomplish this, these organizations collect data from EMS agencies about mistakes, near misses and unsafe conditions and compile it into an expansive database. They identify patterns of failure, trends and areas of concern and share those with participating EMS agencies. The organizations provide anonymity and protection for participating agencies in hopes of preventing similar mistakes from happening in the future. Patient safety organizations are not a regulating body, so discussing errors and near misses does not lead to fines or punishments.

Halverson says one of the most important functions patient safety organizations provide is protection from increased liability. Halverson says it can be difficult to formally discuss safety-related events within your organization because a majority of the discussion can be brought into a court of law in the case of a lawsuit. With a patient safety organization, portions of these discussions can become protected. Although the event itself, medical records, billing information, policies and procedures and action plans following the event are still unprotected, any deliberations or analysis of the event that happen within your agency are protected under a patient safety organization, Halverson says.

The framework for these organizations was created with the passage of the Patient Safety and Quality Improvement Act of 2005, Halverson says. The act was meant to encourage adverse event reporting and focuses on protection, education and prevention in the aftermath of these events. The act was also intended to reduce any raises in the cost of healthcare delivery that might come from medical error. The act estimates that patient safety organizations would decrease adverse preventable events by 3%, which could save up to $425 million nationwide.

Varner says outside of data collection and distribution, the Center for Patient Safety provides resources such as newsletters, online resources, safety alerts, webinars and conferences. Varner says the goal is to promote safety culture as much as possible and to reduce any fear that might surround admitting mistakes in the workplace.

“Healthcare in general has been punitive over the years, and there’s no exception for EMS,” Varner says. “People have a fear of being fired or humiliated if you make a mistake, and it leads to a cycle where people won’t speak up or are afraid to talk about mistakes.”

To combat this, Varner says patient safety organizations help create a paradigm shift to a more educational culture that looks at outcomes as opposed to punitive measures. Varner says agencies should understand recklessness is dangerous and not tolerated, but human error is inevitable and should indicate where we can mentor employees.

Varner says working with the Center for Patient Safety does cost money: About $83 per month for an average-sized EMS organization with one location. With more locations or larger organizations, the cost increases.

To learn more about the Center for Patient Safety, visit centerforpatientsafety.org.

To watch the full webinar, click here.