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SECOND QUARTER 2018
EMS Patient Safety Event Report Welcome! Welcome to the EMS Voluntary Event Notification Tool (E.V.E.N.T.)! This is an aggregate report of the patient safety events reported to E.V.E.N.T. in the second quarter of 2018. We want to thank all of our organizational site partners. For a complete listing of site partners, see page 4. E.V.E.N.T. is a tool designed to improve the safety, quality and consistent delivery of Emergency Medical Services (EMS). It collects data submitted anonymously by EMS practitioners. The data collected will be used to develop policies, procedures and training programs to improve the safe delivery of EMS. A similar system used by airline pilots has led to important airline system improvements based upon pilot reported "near miss" situations and errors.
PROVIDED BY:
The Center for Leadership, Innovation and Research in EMS
IN PARTNERSHIP WITH:
Any individual who encounters or recognizes a situation in which an EMS safety event occurred, or could have occurred, is strongly encouraged to submit a report by completing the appropriate E.V.E.N.T. Notification Tool. The confidentiality and anonymity of this reporting tool is designed to encourage EMS practitioners to readily report EMS safety events without fear of repercussion. “…one paramedic told the other paramedic to “dump” the charge on the cardiac monitor/defibrillator and “hit” the start button on chest compression device. The other paramedic misunderstood and took “hit” meaning to defibrillate the patient.…” – 2Q2018 EVENT Patient Safety Report #9
This is the aggregate Patient Safety E.V.E.N.T. summary report for second quarter 2018.
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Patient Safety Event Reports Sorted Quarterly 2015
2016 2017
2018
Jan - Mar
19
15
10
22
Apr - Jun
18
24
12
9
Jul - Sep
12
9
7
Oct - Dec
4
16
11
Total
53
64
40
EMS Patient Safety Event
As you review the data contained in this report, please consider helping us advertise the availability of
the report by pointing your colleagues to www.emseventreport.com.
31
E.V.E.N.T. Report Completed Online
CLIR Notified of EMS Error
Quarterly/Annual Reports Generated
When an anonymous E.V.E.N.T report is submitted, our team is notified by email. In the United States, the anonymous Patient Safety Event Report is shared with the state EMS office of the state in which the event was reported to have occurred. The state name in the report is then removed and the record is shared through our Google Group and kept for this summary report. Canadian records have the Province name removed, and then the reports are shared through the Paramedic Chiefs of Canada, and kept for inclusion in aggregate reports.
Quarterly Patient Safety Events by Country
USA 9
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0 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Patient Safety Events Reported by State (United States of America) 2
1
Thanks to the Alaska, Colorado, Minnesota, New Jersey, Pennsylvania and Texas agencies and practitioners for supporting this body of knowledge! If your EMS agency has an internal reporting system for patient safety events, we encourage you to have your staff member that receives those reports to also enter them into our anonymous system.
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Vehicle/Aircraft
Training
Procedure/Operations
2018
Medication
1
ua r M y ar ch Ap ril M ay Ju ne Ju ly Au gu st Se pt em O ber ct ob er N ov em b D ec er em be r
2
Medical Control/Protocol
y
3
br
ar
5
Fe
nu
Ja
7
Judgement/Human Error
Dispatch/Response
2017
Equipment Failure/Problem
0
Caused by Another Provider
Year Reported Patient Safety Event Occurred Month of Reported Patient Safety Event
5
9
4
0
Type of Patient Safety Event
5
4
3
2
1
0
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3
0
4 3 2 1 0 Directly Involved Not Directly Involved Other
Nurse or Allied Health Provider
Medical Command Physician
Agency Medical Director
Physician that received patient
Physician - ED
Flight Crew
Community Paramedicine Provider
EMS System Chief/Administrator
5
Other
6 EMS Practitioner
6
Patient died as a result of the event
3
Experienced harm as a result of event
2
Near Miss-Event had potential to harm
Witness
Unknown if patient was harmed
Involvement in Safety Event Role of Person Reporting Incident
4
3
2
1
0
Patient Result of Patient Safety Event
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Number
Patient Safety Event Description
1
Respiratory distress medical emergency involving an 86 year old female. Routine respiratory distress medications were proving to be ineffective in adequately stabilizing the patient. Per protocol, a Magnesium Sulfate 2 gram IV infusion over 20 minutes was initiated. Toward the end of the infusion timeframe, patient developed rapid onset of respiratory depression followed by brief respiratory arrest. Remaining mag sulfate infusion was immediately ceased and BVM ventilations were started due to close proximity to the receiving facility.
Cause and Suggestions The cause of the event was highly likely due to a higher than necessary concentration of magnesium sulfate infused too rapidly. A 50 ml NS bag was used and a possible error in selecting the correct drip set occurred, causing an incorrect infusion volume and time based on an incorrect drug calculation, i.e. calculating a drip rate for a 60 drip set while actually using a 10 drip set. Confirming with partners and other first responders involved in patient care as to exactly what medical equipment was set up for use if the main medical provider was not directly responsible for that task. I.E. Confirming the correct size drip set and volume of infusion fluid and medication. Overall, double checking the accuracy of other's work before implementing specific treatments.
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3
Inadvertently pushed Bicarb rather than D50 due to similarity of delivery devices. Realized error, did not push full pre-filled syringe.
Better communication and safety checks before administering medications and more aggressive treatment interventions. Pre-filled injectors nearly identical once removed from packaging.
Always double-check and verify medications prior to administration. During resuscitation of an elderly male patient Paramedic is an experienced medical provider with (sudden cardiac arrest), the primary paramedic approximately 25 years in EMS. The paramedic inadvertently defibrillated patient while trying to immediately reacted to the error in an appropriate disarm the charged device. Patient had been manner, but had no explanation for why the error moving between multiple rhythms including occurred beyond not being attentive to tasks at hand. pulseless WCT and organized PEA, and had There were no reports of distractions or other possible been defibrillated several times. The cardiac reasons to divert the paramedic's attention away from monitor/defibrillator had been charged to deliver the patient at the time of the error. It is not believed the another shock when the patient reverted to PEA. paramedic was fatigued as the response occurred four Paramedic meant to disarm and dump the stored hours into their work shift, which was preceded by a energy in cardiac monitor/defibrillator, but full 24-hours off from the first shift of the work cycle, inadvertently pushed the "shock" button. No crew and they had been on annual leave for two weeks members were in direct contact with the patient at prior to that shift. the time, and the paramedic noted no change in rhythm. Receiving physician at the hospital was Complacency can occur in any medical provider, advised of the event, and the paramedic whether they are new to the profession or an immediately reported it through the medical chain experienced provider. Focused attention to the patient of command. and the treatment being provided must be adhered to with each and every response.
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Number
4
5
Patient Safety Event Description Patient was involved in a police pursuit during which he hit at least three vehicles on an interstate highway. Patient self-extricated from his vehicle by smashing his driver side window with his hand, then climbing out. Front and side curtain airbags were deployed. BLS crew responded and noted that the patient appeared intoxicated and had a significant injury to his hand. Law enforcement on scene stated that the patient failed the field sobriety test and would be arrested for DUI and a litany of other charges, and would not be going to the hospital until he was processed at the police station. Medical Command was contacted, who ordered that the patient be transported to the hospital. Law enforcement ignored this, and placed the patient under arrest. Incident was thoroughly documented; report was forwarded to Medical Director for immediate review. Formal complaint may also be filed with law enforcement agency internal affairs unit. An ALS crew intercepted with a BLS crew and transported in the BLS ambulance. A thorough medication safety check was not done due to being with a BLS crew. The crew inadvertently give dextrose instead of sodium bicarbonate for a cardiac arrest patient. Accidental over administration of an opiate.
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7
8
Patient administered Cardiazem IVP while in hypotensive state.
Cause and Suggestions Law enforcement interference, failure of crew to advocate for patient, failure of crew to follow medical command orders. Retrain law enforcement personnel on the rights of patients in custody, and the potential consequences of failing to allow the patient to receive medically necessary evaluation and treatment; encourage EMS providers to advocate for patients.
An inexperienced ALS provider did not use the medication safety check as scripted. Verifying with your partner any medications that are anticipated to be given. Make sure the medication label is checked before administration. The ambulance hit a bump in the road and caused the student to push the plunger of the syringe a little too much. Allow ample control of the administration. Provider's failure to be aware of medication usage and protocol.
Increasing staff in-services on infrequently used medications. Law enforcement call for transport of a nine year The crew did not comply with the patient care old patient with behavioral issues. The crew guideline for all patient's with behavioral issues reported the patient to be cooperative when they requiring transport on the stretcher with all safety arrived on scene. The patient was transported on buckles placed. the bench seat of the ambulance and when they arrived at the emergency department the patient went out of the doors and was chased for about one block before a paramedic and hospital security were able to catch up to him.
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Number
9
Patient Safety Event Description
Cause and Suggestions
Patient was defibrillated inadvertently during cardiac arrest resuscitation. Crew documented a communication error occurred between two paramedics involved with the resuscitation – one paramedic told the other paramedic to “dump” the charge on the cardiac monitor/defibrillator and “hit” the start button on chest compression device. The other paramedic misunderstood and took “hit” meaning to defibrillate the patient. The patient was in a non-shockable rhythm at the time and the crew did not report any changes in rhythm or patient condition.
Situational awareness and proper communications was lacking. The first paramedic did not use proper terminology in their directives. The second paramedic did not confirm the orders or parrot back the orders, and was not aware of the cardiac rhythm they were defibrillating. Also, while the paramedic writing the patient care report documented the incident correctly, they failed to notify the medical chain of command of the incident, and it was found during QA/QI review of the patient care report. This is the second inadvertent defibrillation this agency had in 2018; the first being another break in situational awareness - paramedic was not paying close enough attention to their actions and defibrillated a patient when they meant to disarm the charged device. Protocol had been changed years ago to charge defibrillators early during CPR cycles in anticipation of a shockable rhythm, and subsequently decreasing the time without chest compressions while waiting for the machine to charge. This does increase the chances of an inadvertent defibrillation, and should be taken into consideration during protocol development and training. Common terminology for medical procedures should be established in protocol and trained to. Reinforcement of sentinel events reporting through the chain of command to the Medical Director.
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