CY2017 EVENT PSE Summary copy.pages - EMS Voluntary Event ... [PDF]

Welcome! PROVIDED BY:

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 calendar year 2017. 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.

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. “Arrived on scene at police request to find subject and officer in a tussle. Subject was trying to get the officer's weapon and medics moved in to assist. The subject was high on methamphetamines and other drugs, was tased two times without effect… paramedic received scratches on the arm from the subject, who was bleeding freely and shared it with all parties. Once the subject was controlled and handcuffed, he expressed he 'might' have Hepatitis B or HIV...he didn't know..…” – 2H2017 EVENT Violence Report #2

This is the aggregate Patient Safety E.V.E.N.T. summary report for calendar year 2017.

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E.V.E.N.T. EMS Patient Safety Event Report

Patient Safety Event Reports Sorted Quarterly 2014

2015 2016

2017

Jan - Mar

30

19

15

10

Apr - Jun

29

18

24

12

Jul - Sep

24

12

9

7

Oct - Dec

30

4

16

11

Total

117

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.

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 CAN 1

USA 40

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E.V.E.N.T. EMS Patient Safety Event Report

Patient Safety Events Reported by State (United States of America) 5

4

3

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

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Thanks to the Alaska, California, Colorado, Connecticut, Indiana, Kansas, Minnesota, New Hampshire, Ohio, Pennsylvania, Texas, Vermont and Wisconsin 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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E.V.E.N.T. EMS Patient Safety Event Report

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Equipment Failure/Problem

Medication

Caused by Another Provider

Procedure/Operations

gu

ly st pt em O ber ct ob er N ov em b D ec er em be r Se

Au

ne Ju

Ju

ril ay

M

Ap

ch

2017

y

0

ar

2

Judgement/Human Error

10

ar

5

M

ar y

20

ru

nu

30

Fe b

Ja

Year Reported Patient Safety Event Occurred

Training

Dispatch/Response

2016

Vehicle/Aircraft

Medical Control/Protocol

E.V.E.N.T. EMS Patient Safety Event Report

Month of Reported Patient Safety Event

40 9

7

0

Type of Patient Safety Event

12

9

6

3

0

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16 21

3

13 10 7 3 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

23

EMS System Chief/Administrator

30

Other

15

EMS Practitioner

Involvement in Safety Event

Patient died as a result of the event

Witness

Experienced harm as a result of event

8

Near Miss-Event had potential to harm

0

Unknown if patient harmed

E.V.E.N.T. EMS Patient Safety Event Report Role of Person Reporting Incident

16

12 8

4

0

Patient Result of Patient Safety Event

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