4,168
Views
112
CrossRef citations to date
0
Altmetric
Research Article

Patient Safety in Emergency Medical Services: A Systematic Review of the Literature

, BSc, MSc, ACPf, , BSc, , MD, MSc, FRCPC, , ACP, , MD, FRCPC & , MD, MSc, FRCPC
Pages 20-35 | Received 30 Apr 2011, Accepted 23 Aug 2011, Published online: 05 Jan 2012

References

  • Bigham BL, Maher J, Brooks SC, Patient Safety in Emergency Medical Services: Advancing and Aligning the Culture of Patient Safety in EMS. Edmonton, Canada: Canadian Patient Safety Institute, 2010.
  • Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an international classification for patient safety: key concepts and terms. Int J Qual Health Care. 2009;21:18–26.
  • Altman DE, Clancy C, Blendon RJ. Improving patient safety—five years after the IOM report. N Engl J Med. 2004;351:2041–3.
  • Brickell TA, Nicholls TL, Procyshyn RM, Patient Safety in Mental Health. Edmonton, Canada: Canadian Patient Safety Institute and Ontario Hospital Association, 2009.
  • Rust TB, Wagner LM, Hoffman C, Rowe M, Neumann I. Broadening the patient safety agenda to include safety in long-term care. Healthc Q. 2008;11(3 Spec No.):31–4.
  • Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, 1999.
  • Classen DC, Resar R, Griffin F, ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30:581–9.
  • Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff (Millwood). 2011;30: 596–603.
  • Mulrow C, Oxman A. Cochrane Collaboration Handbook [Cochrane review on CD-ROM]. Oxford, England: Cochrane Library, Update Software, 1997.
  • Canadian Patient Safety Institute. Advisory Group. Available at: http://signup.patientsafetyinstitute.ca/English/Initiatives/EmergencyMedicalServices/Pages/default.aspx . Accessed April 27, 2011.
  • Mason S, Knowles E, Freeman J, Snooks H. Safety of paramedics with extended skills. Acad Emerg Med. 2008;15:607–12.
  • Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care. 2008;12:486–94.
  • U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Patient Safety Network. Available at: http://www.PSNet.ahrq.gov/ . Accessed April 18, 2011.
  • Poon EG, Keohane CA, Yoon CS, Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362:1698–707.
  • Haynes AB, Weiser TG, Berry WR, A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.
  • Pronovost P, Needham D, Berenholtz S, An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.
  • Neily J, Mills PD, Young-Xu Y, Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693–700.
  • Atack L, Maher J. Emergency medical and health providers’ perceptions of key issues in prehospital patient safety. Prehosp Emerg Care. 2010;14:95–102.
  • Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775–80.
  • Gandhi TK, Kachalia A, Thomas EJ, Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488–96.
  • Bigham BL, Bull E, Morrison M, Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit. Can J Emerg Med. 2011;13:13–8.
  • World Health Organization. International Classification for Patient Safety. Available at: http://www.who.int/entity/patientsafety/implementation/taxonomy/en/index.html . Accessed December 2, 2009.
  • Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care. 2001;5:261–9.
  • Saunders CE, Heye CJ. Ambulance collisions in an urban environment. Prehosp Disaster Med. 1994;9:118–24.
  • Studnek JR, Crawford J. Factors associated with back problems among emergency medical technicians. Am J Ind Med. 2007;50:464–9.
  • Batchelder AJ, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N. Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study. Anaesthesia. 2009;64:978–83.
  • Brown LH, Hubble MW, Cone DC, Paramedic determinations of medical necessity: a meta-analysis. Prehosp Emerg Care. 2009;13:516–27.
  • Clesham K, Mason S, Gray J, Walters S, Cooke V. Can emergency medical service staff predict the disposition of patients they are transporting? Emerg Med J. 2008;25:691–4.
  • Cone DC, Wydro GC. Can basic life support personnel safely determine that advanced life support is not needed? Prehosp Emerg Care. 2001;5:360–5.
  • Dale J, Williams S, Foster T, Safety of telephone consultation for “non-serious” emergency ambulance service patients. Qual Saf Health Care. 2004;13:363–73.
  • Gray JT, Wardrope J. Introduction of non-transport guidelines into an ambulance service: a retrospective review. Emerg Med J. 2007;24:727–9.
  • Haines CJ, Lutes RE, Blaser M, Christopher NC. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care. 2006;10:213–9.
  • Hauswald M. Can paramedics safely decide which patients do not need ambulance transport or emergency department care? Prehosp Emerg Care. 2002;6:383–6.
  • Knapp BJ, Tsuchitani SN, Sheele JM, Prince J, Powers J. Prospective evaluation of an emergency medical services–administered alternative transport protocol. Prehosp Emerg Care. 2009;13:432–6.
  • McDermott FT, Cooper GJ, Hogan PL, Cordner SM, Tremayne AB. Evaluation of the prehospital management of road traffic fatalities in Victoria, Australia. Prehosp Disaster Med. 2005;20:219–27.
  • Pringle RP Jr, Carden DL, Xiao F, Graham DD Jr. Outcomes of patients not transported after calling 911. J Emerg Med. 2005;28:449–54.
  • Chan EW, Taylor SE, Marriott J, Barger B. An intervention to encourage ambulance paramedics to bring patients’ own medications to the ED: impact on medications brought in and prescribing errors. Emerg Med Australas. 2010;22:151–8.
  • Cushman JT, Fairbanks RJ, O'Gara KG, Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care. 2010;14:477–84.
  • Dewhurst AT, Farrar D, Walker C, Mason P, Beven P, Goldstone JC. Medical repatriation via fixed-wing air ambulance: a review of patient characteristics and adverse events. Anaesthesia. 2001;56:882–7.
  • Eastwood KJ, Boyle MJ, Williams B. Paramedics’ ability to perform drug calculations. West J Emerg Med. 2009;10:240–3.
  • Fairbanks RJ, Crittenden CN, O'Gara KG, Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. Acad Emerg Med. 2008;15:633–40.
  • Frakes MA, High K, Stocking J. Transport nurse safety practices, perceptions, and experiences: the air and surface transport nurses association survey. Air Med J. 2009;28:250–5.
  • Hobgood C, Bowen JB, Brice JH, Overby B, Tamayo-Sarver JH. Do EMS personnel identify, report, and disclose medical errors? Prehosp Emerg Care. 2006;10:21–7.
  • Hobgood C, Weiner B, Tamayo-Sarver JH. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? Acad Emerg Med. 2006;13: 443–51.
  • Hobgood C, Xie J, Weiner B, Hooker J. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types. Acad Emerg Med. 2004;11:196–9.
  • Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics. Prehosp Emerg Care. 2000;4:253–60.
  • Kaji AH, Gausche-Hill M, Conrad H, Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118: 1493–500.
  • LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T. Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care. 2005;9:439–44.
  • MacDonald RD, Banks BA, Morrison M. Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15:923–31.
  • Patterson PD, Huang DT, Fairbanks RJ, Simeone S, Weaver M, Wang HE. Variation in emergency medical services workplace safety culture. Prehosp Emerg Care. 2010;14:448–60.
  • Ricard-Hibon A, Chollet C, Belpomme V, Duchateau FX, Marty J. Epidemiology of adverse effects of prehospital sedation analgesia. Am J Emerg Med. 2003;21:461–6.
  • Seymour CW, Kahn JM, Schwab CW, Fuchs BD. Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care. 2008;12(3):R71.
  • Shaw R, Drever F, Hughes H, Osborn S, Williams S. Adverse events and near miss reporting in the NHS. Qual Saf Health Care. 2005;14:279–83.
  • Stella J, Davis A, Jennings P, Bartley B. Introduction of a prehospital critical incident monitoring system—pilot project results. Prehosp Disaster Med. 2008;23:154–60.
  • Vilke GM, Tornabene SV, Stepanski B, Paramedic self-reported medication errors. Prehosp Emerg Care. 2007;11:80–4.
  • Wang HE, Fairbanks RJ, Shah MN, Abo BN, Yealy DM. Tort claims and adverse events in emergency medical services. Ann Emerg Med. 2008;52:256–62.
  • Wang HE, Weaver MD, Abo BN, Kaliappan R, Fairbanks RJ. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18:213–6.
  • Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Clinical handover of patients arriving by ambulance to the emergency department—a literature review. Int Emerg Nurs. 2010;18:210–20.
  • Carter AJ, Davis KA, Evans LV, Cone DC. Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care. 2009;13:280–5.
  • Evans SM, Murray A, Patrick I, Assessing clinical handover between paramedics and the trauma team. Injury. 2010;41:460–4.
  • Owen C, Hemmings L, Brown T. Lost in translation: maximizing handover effectiveness between paramedics and receiving staff in the emergency department. Emerg Med Australas. 2009;21:102–7.
  • Vilensky D, MacDonald RD. Communication errors in dispatch of air medical transport. Prehosp Emerg Care. 2011;15:39–43.
  • Zimmer M, Wassmer R, Latasch L, Initiation of risk management: incidence of failures in simulated emergency medical service scenarios. Resuscitation. 2010;81:882–6.
  • Becker LR, Zaloshnja E, Levick N, Li G, Miller TR. Relative risk of injury and death in ambulances and other emergency vehicles. Accid Anal Prev. 2003;35:941–8.
  • Bull MJ, Weber K, Talty J, Manary M. Crash protection for children in ambulances. Annu Proc Assoc Adv Automot Med. 2001;45:353–67.
  • De Graeve K, Deroo KF, Calle PA, Vanhaute OA, Buylaert WA. How to modify the risk-taking behaviour of emergency medical services drivers? Eur J Emerg Med. 2003;10:111–6.
  • Johnson TD, Lindholm D, Dowd MD. Child and provider restraints in ambulances: knowledge, opinions, and behaviors of emergency medical services providers. Acad Emerg Med. 2006;13:886–92.
  • King BR, Woodward GA. Pediatric critical care transport—the safety of the journey: a five-year review of vehicular collisions involving pediatric and neonatal transport teams. Prehosp Emerg Care. 2002;6:449–54.
  • Levick NR, Swanson J. An optimal solution for enhancing ambulance safety: implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annu Proc Assoc Adv Automot Med. 2005;49:35–50.
  • Ray AF, Kupas DF. Comparison of crashes involving ambulances with those of similar-sized vehicles. Prehosp Emerg Care. 2005;9:412–5.
  • Ray AM, Kupas DF. Comparison of rural and urban ambulance crashes in Pennsylvania. Prehosp Emerg Care. 2007;11:416–20.
  • Bledsoe BE, Smith MG. Medical helicopter accidents in the United States: a 10-year review. J Trauma. 2004;56:1325–8; discussion 1328-9.
  • De Lorenzo RA, Freid RL, Villarin AR. Army aeromedical crash rates. Mil Med. 1999;164:116–8.
  • Dery M, Hustuit J, Boschert G, Wish J. Results and recommendations from the helicopter EMS pilot safety survey 2005. Air Med J. 2007;26:38–44.
  • Frakes MA, Kelly JG. A survey of adherence to community-generated safety guidelines in rotor-wing air medical programs. Air Med J. 2007;26:100–3.
  • Thies KC, Sep D, Derksen R. How safe are HEMS-programmes in Germany? A retrospective analysis. Resuscitation. 2006;68:359–63.
  • Thomas F, Romig L, Durand J, Hutton K, Handrahan D. Critical issues facing the air medical transport community. The 2003 Air Medical Leadership Congress survey. Air Med J. 2005;24:106–11.
  • Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do specialist transport personnel improve hospital outcome in critically ill patients transferred to higher centers? A systematic review. J Crit Care. 2006;21:8–17; discussion 17-8.
  • Deasy C., O'Sullivan I. Transfer of patients—from the spoke to the hub. Ir Med J. 2007;100:538–9.
  • Duke GJ, Green JV. Outcome of critically ill patients undergoing interhospital transfer. Med J Aust. 2001;174:122–5.
  • Fan E, MacDonald RD, Adhikari NK, Outcomes of interfacility critical care adult patient transport: a systematic review. Crit Care. 2006;10(1):R6.
  • Flabouris A, Runciman WB, Levings B. Incidents during out-of-hospital patient transportation. Anaesth Intensive Care. 2006;34:228–36.
  • Fried MJ, Bruce J, Colquhoun R, Smith G. Inter-hospital transfers of acutely ill adults in Scotland. Anaesthesia. 2010;65:136–44.
  • Gebremichael M, Borg U, Habashi NM, Interhospital transport of the extremely ill patient: the mobile intensive care unit. Crit Care Med. 2000;28:79–85.
  • Hatherill M, Waggie Z, Reynolds L, Argent A. Transport of critically ill children in a resource-limited setting. Intensive Care Med. 2003;29:1547–54.
  • Lee LL, Yeung KL, Lo WY, Lau YS, Tang SY, Chan JT. Evaluation of a simplified Therapeutic Intervention Scoring System (TISS-28) and the Modified Early Warning Score (MEWS) in predicting physiological deterioration during inter-facility transport. Resuscitation. 2008;76:47–51.
  • Lees M, Elcock M. Safety of interhospital transport of cardiac patients and the need for medical escorts. Emerg Med Australas. 2008;20:23–31.
  • Ligtenberg JJ, Arnold LG, Stienstra Y, Quality of interhospital transport of critically ill patients: a prospective audit. Crit Care. 2005;9(4):R446–451.
  • Lim MT, Ratnavel N. A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service. Pediatr Crit Care Med. 2008;9:289–93.
  • Limprayoon K, Sonjaipanich S, Susiva C. Transportation of critically ill patient to Pediatric Intensive Care Unit, Siriraj Hospital. J Med Assoc Thai. 2005;88(suppl 8):S86–S91.
  • Linden V, Palmer K, Reinhard J, Inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation—national and international experience. Intensive Care Med. 2001;27:1643–8.
  • Moss SJ, Embleton ND, Fenton AC. Towards safer neonatal transfer: the importance of critical incident review. Arch Dis Child. 2005;90:729–32.
  • Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe long-distance interhospital ground transfer of critically ill patients with acute severe unstable respiratory and circulatory failure. Intensive Care Med. 2002;28:1122–5.
  • Bair AE, Smith D, Lichty L. Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers. J Emerg Med. 2005;28:403–7.
  • DiRusso SM, Sullivan T, Risucci D, Nealon P, Slim M. Intubation of pediatric trauma patients in the field: predictor of negative outcome despite risk stratification. J Trauma. 2005;59:84–90; discussion 90-1.
  • Fakhry SM, Scanlon JM, Robinson L, Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma. 2006;60:997–1001.
  • Jemmett ME, Kendal KM, Fourre MW, Burton JH. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med. 2003;10:961–5.
  • Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician-verified out-of-hospital intubation: miss rates by paramedics. Acad Emerg Med. 2004;11:707–9.
  • Mackay CA, Terris J, Coats TJ. Prehospital rapid sequence induction by emergency physicians: is it safe? Emerg Med J. 2001;18:20–4.
  • Newton A, Ratchford A, Khan I. Incidence of adverse events during prehospital rapid sequence intubation: a review of one year on the London Helicopter Emergency Medical Service. J Trauma. 2008;64:487–92.
  • Parwani V, Hoffman RJ, Russell A, Bharel C, Preblick C, Hahn IH. Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques. Prehosp Emerg Care. 2007;11:307–11.
  • Pratt JC, Hirshberg AJ. Endotracheal tube placement by EMT-Basics in a rural EMS system. Prehosp Emerg Care. 2005;9:172–5.
  • Svenson JE, Lindsay MB, O'Connor JE. Endotracheal intracuff pressures in the ED and prehospital setting: is there a problem? Am J Emerg Med. 2007;25:53–6.
  • Tiamfook-Morgan TO, Harrison TH, Thomas SH. What happens to SpO2 during air medical crew intubations? Prehosp Emerg Care. 2006;10:363–8.
  • Wang HE, Cook LJ, Chang CC, Yealy DM, Lave JR. Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation. 2009;80:50–5.
  • Wang HE, Kupas DF, Paris PM, Bates RR, Costantino JP, Yealy DM. Multivariate predictors of failed prehospital endotracheal intubation. Acad Emerg Med. 2003;10:717–24.
  • Wang HE, Lave JR, Sirio CA, Yealy DM. Paramedic intubation errors: isolated events or symptoms of larger problems? Health Aff (Millwood). 2006;25:501–9.
  • Wang HE, Sweeney TA, O'Connor RE, Rubinstein H. Failed prehospital intubations: an analysis of emergency department courses and outcomes. Prehosp Emerg Care. 2001;5: 134–41.
  • Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care. 2007;11:213–8.

Reprints and Corporate Permissions

Please note: Selecting permissions does not provide access to the full text of the article, please see our help page How do I view content?

To request a reprint or corporate permissions for this article, please click on the relevant link below:

Academic Permissions

Please note: Selecting permissions does not provide access to the full text of the article, please see our help page How do I view content?

Obtain permissions instantly via Rightslink by clicking on the button below:

If you are unable to obtain permissions via Rightslink, please complete and submit this Permissions form. For more information, please visit our Permissions help page.