EMS Event Reporting Program “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

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 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 Safety What 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 Know Change 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 Room922.5% MD512.5% Fire820% Ambulance1025% Patient37.5% Other512.5% Total40100%

EMS Event Characteristics “We have the same issues” Event Type#% Communication2460% Medication717.5% Destination1332.5% Patient Care3690% Billing12.5% Documentation-ePCR1435% Response Time1230% 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 ModelObjective Handoff (I PASS the BATON) Improves communication during handoffs Situation Monitoring (SBAR)Communicates critical info that requires action immediately Check-BackTechnique to assure effective communication Call-OutUsed to communicate critical info CUSTechnique 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 Participation Contra 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