EMS Event Reporting EMS Event Reporting Program Program

“Patient Safety First”“Patient Safety First”Effective December 1, 2007

Contra Costa EMS Agency

EMS Event Reporting Design

• Formerly Unusual Event Reporting

• Redesigned patient safety and recognition program

• Prioritizes patient safety

• Clear line of reporting and follow-up

EMS Event Provider Actions

Assure patient safetyReport to on-duty officer or supervisor

Complete report formDeliver report to supervisor

Agency QI Coordinator Actions

Accept ReportBegin Fact Finding

Determine Nature of EventDetermine Significance of Event

Internal review with consulting partiesDetermine actions required

Implement action planEnter Data for Agency Analysis

Quarterly non-identified aggregate data submitted to EMS Agency

EMS Agency Actions

Intake appropriate events for follow-upRefer events to appropriate agencies for

follow-upReview notification events for follow-up

Facilitate event interagency event reviewConduct independent review as needed

Determine appropriate actionsCollect data and analyze patient safety

aggregate data

Criteria for notification met?

1798.200 Health and Safety Code Criteria EMS Agency notification determination made

Appropriate Agency Report Made

Prehospital Event Data Analysis

Agency QI Coordinators EMS Agency QIIdentify develop and implement

patient safety initiatives designed to benefit EMS system

Contra Costa County EMS Event Reporting-Redesign8/14/07

So…what is an EMS Event?

• Any event that has led to or has the potential to lead to an adverse patient outcome

• “Great Catches” • Community event that may cause public concern• Exemplary care in the field• Events that represent a threat to public health and

safety defined by 1798.200 CA H&S Code

Why is this a better system?

• Helps us focus on what is REALLY important– Patient and Provider Safety

– Exemplary Care in the field

• Early notification system– Pink Flags

– Red Flags

• When you catch problems when they are small they stay small….Gordon Graham

Patient SafetyWhat the Experts Know …

• Events cause enormous amount of injury, suffering and death

• They are preventable• Multiple events

contribute to the most serious outcomes

• Punishing people does little to improve overall system safety.

Root Causes of Patient Safety Events

• Patient care delays causing harm or death (JCAHO)

– Communication (84%)

– Patient Assessment (75%)

– Orientation and Training (46%)

Root Causes

• Fire Fighter Deaths (NIOSH)

– >20% firefighter deaths occur on roadways

– Root causes: seat belt use and scene safety

What’s in for the EMS system?

• Focus on positive corrections

• Early identification of system problems

• Promotes accountability and respect

• Reduces conflicts between HR, HIPPA, agency privacy practices

• Recognition system of field care excellence

Implementation Problem #1: “We punish people for making mistakes”

• “The single greatest impediment to improving system-wide safety”

• Most of what we deal with is “Human Error”

• What is Human Error? The honest mistake.

What You Need To KnowChange takes time

Movement in

Reporting as the Learning

Grows

Report on equipment

Report on events you observe

Report on own human error

Report on own knowing violation of policy

EMS Provider Responsibility

• Patient safety

• Accountability

• Report

Who can report

EMS Event Reporting Jan-Dec 2007

Reporting Source # %Emergency Room 9 22.5%

MD 5 12.5%

Fire 8 20%

Ambulance 10 25%

Patient 3 7.5%

Other 5 12.5%

Total 40 100%

EMS Event Characteristics“We have the same issues”

Event Type # %

Communication 24 60%

Medication 7 17.5%

Destination 13 32.5%

Patient Care 36 90%

Billing 1 2.5%

Documentation-ePCR 14 35%

Response Time 12 30%100% of events where communication played a factor also affected patient care.

AHRQ: Communication is a major factor in >65-75% of sentinel events

High Risk Communication

• Patient Handoffs (2006 EMS Annual Report)

– > 102,000 handoffs – 20% increase from 2005– Potential for 4 or more different communications

for each patient transport• First Responders to 911 Transport

– May involve up to 5 responders (Fire & Transport)• Transport to ED personnel

– May involve 1-2 medics and 2 or more nurses, MD• Base Hospital Communication• Receiving Hospital Communication

Evidence Based Patient Safety: Communication Models

Model ObjectiveHandoff

(I PASS the BATON)

Improves communication during handoffs

Situation Monitoring (SBAR) Communicates critical info that requires action immediately

Check-Back Technique to assure effective communication

Call-Out Used to communicate critical info

CUS Technique to communicate pt safety concern

Scenario: Things didn’t go according to plan

• Mary Medic reports a 2 hour offload delay at an ED with a 22 year old patient in active labor.

• Patient ended up delivering in the ambulance

Scenario: Great catch• Joe Medic during a

routine check of equipment finds a defibrillator not working. The device is replaced but the time it took could have caused a delay if his unit had been dispatched.

Scenario: Community event causing public concern

• Any event of interest to the press.

• Multi-casualty Incidents• Report of ambulance or fire

vehicle accidents• EMS needs our providers

eyes and ears!• Report occurs through chain

of command

Scenario: Exemplary Care

• First responder ALS medics Jones and Allen arrive at a scene of a near-drowned 3 year old. They provide excellent CPR and the child has ROSC.

• Response time is excellent and due to the efforts the child makes a full recovery.

Scenario: Threat to Public Health and Safety

• Citizen Smith calls reporting he believes his elderly mother received an arm injury while being transported. He is angry and very upset. The medics involved report the situation was chaotic and the scene unsafe.

Stakeholder ParticipationContra Costa QI Committee Constituents

• Con Fire• AMR• El Cerrito Fire• Pinole Fire• Rodeo Hercules• JMMC-Concord

• San Ramon Fire• Moraga Orinda Fire• East Contra Costa Fire• Richmond Fire• Contra Costa EMS • JMMC-Walnut Creek

Questions