data collected will be used to develop policies, procedures and training programs to improve the safe delivery of EMS. A
FIRST QUARTER 2016
E.V.E.N.T. Near Miss Report Welcome!
PROVIDED BY:
Welcome to the EMS Voluntary Event Notification Tool (E.V.E.N.T.)! This is an aggregate report of the near miss events reported to E.V.E.N.T. for first quarter 2016. 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.
The Center for Leadership, Innovation, and Research in EMS (CLIR)
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.
“Experienced Female EMT transporting a Mental Health Patient from ER to Inpatient Treatment Facility was Sexually Assaulted by the patient while preparing to exit the Ambulance at the receiving facility. Due to Ambulance Construction (Type 1 Pickup Chassis) the EMT Driving was unaware of the assault occurring. – 1Q2016 EVENT Violence Report #12 This is the aggregate Near Miss E.V.E.N.T. summary report for first quarter 2016.
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E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
Near Miss Events Quarterly 2015 2016
2013
2014
Jan - Mar
4
0
4
Apr - Jun
3
1
2
Jul - Sep
5
5
5
Oct - Dec
7
6
2
Total
19
12
13
Near Miss Event Occurs with EMS
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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.
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E.V.E.N.T. Report Completed Online
CLIR Notified of EMS NME
Quarterly 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 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.
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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
E.V.E.N.T. Near Miss Report FIRST QUARTER 2016
Near Miss Events by State (United States of America)
5
4
3
2
1
3
E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
4
E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
Near Misses in Canada and U.S. Territories
N. Mariania Islands 0 American Samoa 0 Guam 0 Puerto Rico 0 US. Minor Islands 0 US. Virgin Islands 0 Canada* 0 US Total
4 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Near Miss Events Across Agency Characteristics
Urban 0%
Service Area Urban
Suburban 25%
Suburban Rural Remote/Frontier
Rural 75%
Other/More than One Selected
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E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
Frequency of NME by Agency Ownership 10 9 8 7 6 5 4 3 2 1 0
Department Type 6 5 4 3 2
3
1 0
0 Volunteer
1 Combination, mostly volunteer
Paid
0 Combination, mostly paid
0 Other/More than One Selected
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E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
Level of Organization 3.5 3 2.5 2 1.5
3
1 0.5 0
1 0 EMR or BLS First Response
0 ALS First Response
BLS Transport
ALS Transport
0 Air Medical Transport
Employment 3.5 3 2.5 2 1.5
3
1 0.5
1
0 Full-Time
0 Part-Time
Volunteer
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E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
NME Occurrence During EMS Response Timeline 3 2
2
2 1
1
1
1
0
0
0
0
0
0
0
0
0
0
Year Reported Near Miss Event Occurred 5 4 3 2 1 0 2014
2015
2016
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E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
Month of Reported Near Miss Event 3
2
1
0
Time of Reported NME 1.2
1
0.8
0.6
0.4
0.2
0
9
E.V.E.N.T. Near Miss Report
FIRST QUARTER 2016
Hours into Shift at time of NME 2.5 2 1.5 1 0.5 0 0-4 Hours
5-8 Hours
9-12 Hours
13-16 Hours
17-20 Hours
21-24 Hours
More than 24 Hours
Contributing Factors to Near Miss Events: As Reported by Providers Frequency
Frequency
Accountability
0
Situational Awareness
1
Command
0
SOP/SOG
0
Communication
1
Staffing
0
Decision Making
1
Task Allocation
0
Equipment
0
Teamwork
0
Fatigue
1
Training Issue
0
Distracted Driver/Pilot
0
Unknown
0
Horseplay
0
Weather
1
Human Error
1
Violent Patient
0
Individual Action
0
Violent Non-Patient
0
Procedure
1
Inadequate Lighting
1
Protocol
0
Other
0
10
E.V.E.N.T. Near Miss Report #
Description
1
Ambulance unit was returning to base from an interfacility transfer; roads were icy in some areas. Driver came upon a slippery section of the interstate, let off the throttle and the back end of the ambulance got loose. Vehicle entered median and flipped onto the passenger side where it stayed. No injuries reported; no patient involved. While operating the ambulance traveling flow of traffic I traveled through a controlled intersection and nearly struck the left side of a small sedan that was attempting to make a left turn through a red light.
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3
4
FIRST QUARTER 2016
Lessons Learned/System Change Use care while driving at all times, be aware of surroundings, drive slow when indicated. Event recognition with all employees; roundtable discussion on situation.
The intersection is too dark to adequately see vehicles lined up waiting to turn left. Better situation awareness and emphasis during driver training will create greater recognition of this danger and improve a vehicle operators chances of anticipating and defending from a crash. Improved driver training. As reported: "Unit was returning to base from the shop. Existing policy indicates employees must have at least 8 We were traveling west bound on XXX. The wreck occurred hours of unscheduled time prior to a shift. This employee just before the XXX exit. The posted speed limit was is also a resident firefighter, but we cannot confirm the 45mph. I assume we were traveling the speed limit. I do employee was "resting" prior to this EMS shift. For cause not believe the driver of the unit hit the brakes before drug testing was performed. hitting the telephone pole. It was not raining, foggy, snowing, etc. There was not a visibility issue. We were Encourage employees to report fatigue. Meet with both wearing our seat belts. We were not running employees that have repeated reporting to ensure they emergency traffic. After striking the telephone pole the are able to ensure ability to arrive to work rested and driver hit the brakes and brought the truck to a stop on the capable of functioning for 12 hour shift. side of the road. After the wreck the driver reports she had fallen asleep and that caused us to wreck. I had no time to warn the driver of the telephone pole." Working a 28 year old cardiac arrest due to drug overdose. I changed this in my phone so the numbers were nowhere Hectic scene with nearly 15 bystanders which included the near each other. I need to have more awareness of the individual who gave her the drugs and the patients family button that I hit. who were aware of the drugs. Administered 10mg of Narcan in addition to epinephrine. Patient was in a PEA. I work in two states and have multiple med control Called Med control to get orders for more Narcan because numbers and hit the wrong button on my phone. I was we had hit he max per protocol. Med control ordered an unaware of the problem because med control answered additional 10 mg given 5mg at a time. Resuscitation efforts the phone "medical control this is dr...." There was no were terminated shortly after and family was transported indication that it was the wrong hospital. I identified to hospital. Just prior to transport I realized I had called myself my service the town we were in and painted a Med control at a different hospital in another state. picture of the scene. To prevent this from happening again med control should state the hospital name as they do when giving radio reports.
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