Your Captain Speaking: Managing Threats and Errors

Mistakes happen in medicine—mistakes in patient treatment as well as transportation. Some of them allow EMTs and paramedics to be hurt by patients. From a safety perspective, we have significant room for improvement. 

Let’s start by talking about some types of errors. Generally errors can be categorized into three types: intentional, unintentional, and related to proficiency. 

Intentional—“I know what the rule or procedure is; I’m just not going to follow it.” Here’s one I was guilty of: When shoulder straps were first added to the stretchers, we were told to use them. Lots of us just tucked them under the mattress. Truth be told, even today lots of shoulder straps are not being used as they should be. It’s not likely you’ll read on a run report, Patient was not secured with shoulder straps because we just didn’t feel it necessary. You can surely cite other examples—be honest with yourself. 

Unintentional—Sometimes called a “slip and trip,” it might be an older procedure or a new one we should have known but just didn’t remember. Scenes can be very chaotic and stressful. Easy things become hard, hard things become impossible. Could unintentional mistakes be more frequent for those who don’t stay in the books on procedures or perhaps ignore CEU opportunities?

Proficiency—We know what to do and how, but muscle memory just fails us. Starting an IV is a perishable skill—not just the needle-stick part but the whole process of setup, insertion, securing, and flushing. An endotracheal procedure requires significantly more proficiency. A close neighbor to proficiency is recency. This means not only the number of times you’ve actually intubated a patient but also how recently. Pilots must perform a landing every 90 days to be technically current, but if it’s been nearly that long, our confidence in the procedure is reduced even if we’ve done thousands of landings! Are you as confident with an intubation if you haven’t done a real one in the past six months? Is there a way to improve your odds? 

Other Threats

Additionally, errors related to EMS can be attributed to a few other threats. These can come from all angles. Before starting a shift I would ask myself, “What are the threats today?” Maybe I was working with an EMT I’d never worked with before or a Basic new to ALS operations. It could have been the weather: snow, thunderstorms, heat index. The better you can identify and verbalize the threats, the less likely you’ll be surprised by them.

Legal threats—We face these every day, but we generally know how to minimize them. Follow your procedures, treat your patients with respect, and document properly as a good start.

Physical threats—If you’ve never been hurt lifting or moving a patient, you still need to know it’s a real problem in EMS. Scene safety is top-of-the-list at any call, and its lack will cause us to stage or call for additional units. What’s the nature of the call? Nursing home or a bad neighborhood? 

Environment—If you’re in EMS, you’re out there in the heat, cold, snow, rain, and every combination of them.

Fatigue—Many of us have worked multiple jobs or back-to-back shifts. Fatigue is a subtle and sneaky threat. In the airline industry, if you’re excessively fatigued, you call in and say that, and you don’t fly. There is no retribution. There will be unhappy people, but you don’t lose your job. 

Vigilance is directly related to fatigue. Staying in the game mentally, not skipping steps because you’re tired, can be tough. Fatigue degrades your performance as surely as being drunk. 

Personal problems—There are times when problems in areas like romance or finance can run at a boil or become overwhelming. They can become distractions that interfere with our work. 

Consider these threats and errors as we further discuss common scenarios paramedics face.

Threat Management

The first thing you need to do is to do a self-examination before the shift. What are your current threats? Be honest with yourself. Getting into a problem on this shift is not going to make things better, so how can you deal with it? 

You’ve been trying to lose weight, you haven’t eaten, and you know your blood sugar is low. This is not something you need to open up and discuss with your partner or supervisor. What is appropriate to talk to your partner about is something like, “I strained a muscle yesterday, so I might be moving a little slower.” Then you can discuss how they might be able to help.

Ask your partner how they’re doing and what potential snags they foresee for the day. If your scheduled off time is 5 p.m. and there are almost always late calls, is there schedule pressure to be off right on time? Is it the last day of a set of shifts? Watch out for each other on the fatigue issue and back each other up.

What are the threats in your ambulance? It used to be we had a fluid bag with all the normal saline, lactated Ringer’s, and premixed lidocaine all in the same container. It was easy to reach into the bag and remove the wrong fluid. Only after some bad outcomes did it come out that others were making the same mistake. 

At the beginning of the shift or on the first call, do you open the valve to the main oxygen tank and then leave it open for the rest of the shift? We are often in a hurry; some of us may have put a nasal cannula on a patient and forgotten to turn on the oxygen flow. Turning on the main oxygen tank and leaving it on seems like a good idea, but it’s not. If your ambulance is in a crash and a line is broken, you could be feeding medical-grade oxygen to a fire! Each time I wanted O2, I would work from the tank to the flow meter to the cannula, then backward when removing. Have you ever startled a patient wearing a cannula with a big blast of pressure as you turned on the main tank? I certainly have, but I adapted.

Earlier we posited it had been six months since you intubated for real. How can you mitigate this threat? Here are some suggestions: Admit you might be rusty. Review the procedure mentally. Recognize the common mistakes. For me it was rushing to place the tube without making sure all was ready beforehand. Check tube placement using several methods. Have a plan if it goes well and if it does not. Can you list at least 10 observations that indicate proper tube placement?

Error Management

If you’ve never made a mistake on a call, my compliments, because I have made some zingers. The secret to error management is noticing your error early and fixing it. Smaller errors are easier to fix than big ones, which has a big implication for you and your partner: Allow them to have your back! If they see something, they should say something!

Here’s an example: We want to start an IV on a minor trauma call, and I grab a 20-gauge needle. My partner, Angie, thinks it would be better if we used an 18-gauge, and she says, “You want an 18-gauge?” In this example both are fine to use, but I tell her, “Good idea. Hand me an 18-gauge please.” We are diplomatic about it in front of the patient, but the important point is that if she sees a reason to change needles, Angie has her head in the game and has my back. 

Error management also works in the other direction. If I saw her making a mistake, Angie knows I would gently suggest an alternative. The key to this interaction is that we have discussed and maintain an open and accepting attitude toward corrections in either direction.

Threat and error management goes hand in hand with crew resource management. CRM is not a static model in the airline industry; rather, it has changed and adapted over time. It can be used the same way in EMS but must be adapted to some differences. The same is true with TEM. The road has already been laid, and it’s a natural addition. 

Start today. Talk to your partner and ask questions that have been raised here. It’s a start.

Dick Blanchet (ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Maj. Ben Blanchet, BS, MS, is a C-130J evaluator/instructor pilot in the U.S. Air Force with a cumulative 19 years in civil and military aviation. He is also a trained aviation safety program manager and mishap investigator.