A National Center for EMS Provider andPatient Safety: Helping EMS Providers Help Us

High-quality EMS systems that are safe for both providers andpatients are essential to providing optimal care to the acutely ill andinjured andare also necessary to provide the first line of care for victims of natural andmanmade disasters.¹ The EMS industry must achieve a culture of safety andhigh reliability if it is to meet the expectations of the new millennium. A national center to gather andorganize information pertaining to provider andpatient safety would advance the interests of our public andproviders.

Since the publication of To Err is Human hundreds of publications andthousands of patient safety programs have been created.² While hospitals andother care facilities function under legislative andoversight body regulations (including The Joint Commission) requiring reporting andcause analysis, similar requirements andprograms are largely absent for prehospital care. Our challenge is to design systems that decrease the likelihood of patient or provider harm.

How safe is EMS? The truth is, we simply do not know. Aside from a small series of reports andanecdotes, we know very little about national patient safety in EMS. It is clear that prehospital care is challenged by many factors known to augment error: time urgency, interruptions, an uncontrolled environment, stress, variable initial training, andinconstant continuing education. The first task of a federal safety initiative must be to define the current state–developing error nomenclature for EMS andassessing the current frequencies andpatterns of error.

While some experts have addressed local error patterns andoffered suggestions to limit these, there are no coordinated andfederally adopted measures of patient safety andquality in EMS. Before creating comprehensive safety guidelines, we need evidence to answer basic questions like: What equipment should be taken into what types of calls? How much time should be spent on scene? What procedures should be done on scene? Which should be done in the ambulance before departing? Which should be done en route? These are complex andcommon questions, currently left to haphazard practice patterns.

The Institute of Medicine (IOM) considers nationwide reporting of medical errors and“near misses”–errors without harm–essential to improving safety.² Gwinn andothers initiated a service called “MEPARS” (www.mepars.com) to allow anonymous reporting of EMS errors.³ The first advisory based on these data led MEPARS to recommend against combined side-by-side carrying of premixed IV solutions with other IV solutions. While this simple recommendation can save lives, it is troubling that it required over two decades for error prone EMS practices to be recognized. MEPARS is shackled by limited participation andlimited funding. EMS leaders must champion participation in this process. MEPARS has received only approximately 30 reports in the past 2 years despite over 30 million patient transports. Surely the rate of errors in EMS is greater than one in a million. Mandatory anonymous reporting to a funded national center would allow systematic solutions to recurring threats to patient andproviders.

For industries where human error can lead to devastating consequences, the goal has been for the development of a culture that has characteristics that have become known as a high reliability organization (HRO). Gaba summarized the elements of an HRO as 1) systems, structures, andprocedures conducive to safety andreliability are in place; 2) intensive training of personnel andteams takes place during routine operations, drills, andsimulations; 3) safety andreliability are examined prospectively for all the organization's activities, andorganizational learning by retrospective analysis of accidents andincidents is aggressively pursued; and4) a culture of safety permeates the organization.⁴ Like aviation andanesthesia, EMS must embrace the challenge to become a high reliability organization.

The Anesthesia Patient Safety Foundation (APSF) www.aspf.org is a model successfully leading anesthesia to becoming an HRO. Its mission is simple: “To ensure that no patient is harmed by anesthesia.”⁵ Largely because of their efforts, the incidence of anesthesia-related death during general anesthesia has gone from 1 in 10,000 cases to 1 in 2000,000–300,000. The APSF offers a wealth of training resources including but not limited to newsletters, clinical safety tools, educational tools, targeted safety initiatives, grants, data collection andanalysis, andmaintaining an active andup-to-date website.

Aside from measures to safeguard patients, EMS systems andleaders must also care for the caregivers, a neglected area. Nadine Levick raised national awareness, noting “Despite the large strides that the automotive industry, occupational health andsafety as well as public safety have made in the last 30 years, this expertise has not yet been translated to the safety of ambulance transport.”⁶ She repeatedly decries the absence of databases in this country that track ambulance crashes, the lack of vehicle crash safety standards for ambulances, andinconstant protective equipment standards. A national center should collect these data andguide safer designs andprocedures to aid both the provider andthe patient.

Occupational injuries other than ambulance crashes are also very common. EMS providers are subject to a myriad of musculoskeletal injuries, are victims of violence, are exposed to potentially infectious body fluids andairborne pathogens andstress-related illnesses. In 2000 the rates of injury reported to the Department of Labor were higher than any other industry.⁷ An urban study reported rates of occupational injury of 50 cases per 100 full-time male EMS workers and86 per 100 females.⁸ Another study from six New England states reported back injury rates of 25 per 100 full-time employees per year andan assault rate of 20 per 100 employees per year.⁹ Pandemics andother emerging infectious disease hazards require us to plan for the safety of our emergency responders.

There should be a national center to collect data andinvestigate every line-of-duty serious injury or death among prehospital providers. Similar to the Fire Fighter Fatality Investigation andPrevention Program (www.cdc.gov/niosh/fire),¹⁰ this program is essential to understand that hazards associated with EMS service andsuggest programs to reduce injury anddeath.

The fire services of this country have done a spectacular job of decreasing fires with an array of prevention strategies. In many communities a fire is looked at by the fire service as a failure of prevention. Too many EMS systems continue to operate in the “you call, we haul” paradigm with minimal focus on injury or illness prevention. Our patients andproviders will be well served by emulating the success of our fire service colleagues engaging in EMS based health promotion andinjury prevention activities as suggested in the 1996 EMS Agenda for the Future: Implementation Guide.¹¹

Some federal efforts exist; the National Highway Traffic andSafety Administration (NHTSA) www.nhtsa.gov.org has provided a federal home for EMS since its inception. Currently, many important NHTSA initiatives are underway including sponsorship of the National EMS Information System (NEMSIS) www.nemsis.org.¹² Other worthy programs include the National EMS Scope of Practice Model; EMS Work Force of the 21st Century; EMS Research Agenda andothers. These laudatory efforts do not obviate the need for a new center that is housed in NHTSA or elsewhere.

In 2006 the IOM published Future of Emergency Care: Emergency Medical Services at the Crossroads the most comprehensive analysis of the status of Emergency Medical Services (EMS) in the United States since the inception of modern EMS in the 1970s. It makes the plea that the six health care quality aims expressed in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century should be the goals of modern EMS systems namely; safe, effective, patient-centered, timely, efficient andequitable. To achieve these goals we need a national center for EMS provider andpatient safely.

The authors would like to acknowledge the Jewish Healthcare Foundation for their support of EMS patient safety research.

The authors would like to acknowledge Daniel Patterson, PhD, David Hostler, PhD, Donald Yealy, MD, andHenry Wang, MD for their insights andeditorial assistance.

Editor's Note: Dr. Paris is a Past President of NAEMSP, was one of the founding members of NAEMSP, andis a recipient of the Ronald D. Stewart Award. Dr. O'Connor is the Immediate Past President of NAEMSP andis currently the President of Advocates for EMS.