EMS Leaders Detail How Patient Safety Organizations Benefit EMS

With patient safety problems in EMS, often agencies only see the tip of the iceberg, says Lee Varner, director of the Center for Patient Safety. Varner says joining a patient safety organization (PSO) can present organizations with the tools to see the deeper root of the issues and handle them more efficiently.

In a webinar hosted by the Center for Patient Safety on December 15, supervisors from three different EMS agencies detailed the benefits their organizations have experienced from joining a PSO.  

PSOs, created with the help of the Patient Safety and Quality Improvement Act of 2005, help provide legal protections for organizations during review of any safety-related incidents, and provide a database of mistakes, near misses and unsafe conditions that have been reported by EMS organizations previously, so agencies can identify patterns of failure and implement preventative measures in their own organizations, says Eunice Halverson, patient safety specialist with the Center for Patient Safety.

John Romeo, chief medical officer of Saint Charles County Ambulance District in Missouri, says joining a PSO helped his organization create a culture that was more focused on safety. Romeo says with the help of the PSO’s accessible database of safety events, his organization was able to realize a majority of errors were based on the system, not on the individual practitioners.

For example, Romeo says his organization quickly realized one of the main causes of most of their medication errors was the lack of a prevention method. Their team created a cross check system that allowed practitioners to take a second to double check they were giving the right medications, even during critical calls and cardiac arrests.

Romeo says this was strange for some practitioners at first, but it showed the importance of preventing errors and quickly prevented some near misses.

Joining the PSO helped his organization further embrace safety culture, and they implemented a peer review program to catch any system inefficiencies and provide essential, safety-related feedback. Romeo says the program also helps foster an environment where providers don’t feel like they are being punished or singled out for making mistakes, and allows them to distinguish between intentional and unintentional issues in care.

Rodney Dyche, director of corporate training for Paramedics Plus, says turning to a PSO helped change his company’s culture from punitive to one that emphasizes education. One of the biggest challenges in this process was promoting consistency in reporting safety incidents, Dyche says.

For example, some of the 250 mattresses and stretchers the company uses became contaminated because of a stitching design that made it difficult to clean, and delays in reporting created potential for fluid exposure to staff and patients. If it was reported sooner, the company could have identified the problem and created a solution before it became an issue.

“It’s not unusual for staff to feel the world is punitive against them, and failure to report becomes enormous because of the fear of consequences,” Dyche says.

Dyche says the process takes time, comparing it to turning a boat around, but the results are worth it. After some time, employees begin to trust everything they report will not result in punitive actions unless it’s a deliberate behavioral choice by the employee, Dyche says. This bolsters data collection and, in turn, helps create an environment where providers can learn from mistakes and prevent them from happening in the future.

Jennifer Fletcher, director of patient care and staff development of the Air Evac LifeTeam, based in Missouri, says joining a PSO is a way to add another tool agencies can use to ensure safety within their organization. Fletcher says their company has safety management systems in place as a requirement, but they generally dealt with operational safety.

“We thought if we did operationally safety well, patient safety would follow,” Fletcher says. “But that wasn’t necessarily true.”

Over the last two years, Fletcher’s agency has implemented a patient safety management system with the help of a PSO.  Fletcher says joining a PSO helped the organization with safety event reporting, legal protection and creating an environment that accelerates learning and ensures safety.

“It sends a statement to providers that patient safety is just as important as any other element of the operation,” Fletcher says.

For more information on the Center for Patient Safety, visit centerforpatientsafety.org.