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THIRD QUARTER 2013
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 the third quarter of 2013 (July 2013 through September 2013). 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.
“…EMS deals with a lot of situations that can turn from good to bad really quick and I think something needs done. This website is a great idea, but if we do not act on all the data you get, the point of the website is pointless. No one was hurt in this incident, but someone could have been very quickly.” – 3Q2013 EVENT Provider Violence Report #7
This is the aggregate Near Miss E.V.E.N.T. summary report for Third Quarter 2013.
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Table 1: Near Miss Events Quarterly 20102011 Jan - Mar Apr - Jun Jul - Sep Oct - Dec
1 1
Total
2
Near Miss Event Occurs with EMS
2012
2013
1
4
8 10 19
3 5
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.
2
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 THIRD QUARTER 2013
Figure 1: Near Miss Events by State (United States of America)
5
4
3
2
1
Figure 1.1 FEMA Region Map of United States
Near Miss Events by FEMA Region
This period’s US near miss event reports were in FEMA regions 4, 5, 6 and 9.
Figure 1.1 Notes: Map includes all Ten FEMA Regions as determined by Department of Homeland Security.
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 2: Quarterly 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
6 0
1
2
3
4
5
6
7
Quarterly Frequency of Near Miss Events Across Agency Characteristics 0%
Figure 3: Service Area Urban
33%
34%
Suburban Rural Remote/Frontier
0% 33%
Other/More than One Selected
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 4: Frequency of NME by Agency Ownership 10 9 8 7 6 5 4 3 2 1 0
Figure 5: Department Type 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0
4
1 0 Volunteer
Combination, mostly volunteer
1 Paid
Combination, mostly paid
0 Other/More than One Selected
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 6: Level of Organization 7 6 5 4 6
3 2 1 0
0 EMR or BLS First Response
0 ALS First Response
0 BLS Transport
ALS Transport
0 Air Medical Transport
Figure 7: Employment 7 6 5 4 3
6
2 1 0 Full-Time
0 Part-Time
0 Volunteer
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 8: Annual Responses of NME Agency 3.5 3 3 2.5 2 1.5 1
1
1
1 0.5 0
0
0
0
Figure 9: Near Miss Event Setting 7 6 5 4 3
6
2 1 0 Ground Based EMS
0 Air Medical EMS
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 10: NME Occurrence During EMS Response Timeline 3 2
2
2
2 1
1
1
1 0
0
0
0
0
0
0
0
0
Figure 11: Year Reported Near Miss Event Occurred 7 6 5 4 3 2 1 0 2013
2012
2011
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 12: Month of Reported Near Miss Event 3.5 3 2.5 2 1.5 1 0.5 0
Figure 13: Time of Reported NME 2.5
2
1.5
1
0.5
0
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 14: Environmental Visibility During Near Miss Event 7 6 5 4 3
6
2 1 0 Light
0 Dusk/Dawn
0 Dark
Figure 15: Weather During NME 7
6
5
4
3
2
1
0 Clear & Clear w/ Clear w/ Cloudy & Cloudy & Cloudy & Cloudy & Cloudy & Fog w/ Fog w/ Not Dry Wet Frozen Dry Rain Snow Sleet Freezing Reduced Poor Reported Surfaces Surfaces Rain Visibility Visibility
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Table 2: Contributing Factors to Near Miss Events: As Reported by Providers Frequency
Frequency
Accountability
0
Situational Awareness
2
Command
0
SOP/SOG
0
Communication
1
Staffing
0
Decision Making
0
Task Allocation
0
Equipment
1
Teamwork
1
Fatigue
0
Training Issue
1
Distracted Driver/Pilot
0
Unknown
0
Horseplay
0
Weather
0
Human Error
2
Violent Patient
0
Individual Action
1
Violent Non-Patient
2
Procedure
0
Inadequate Lighting
0
Protocol
0
Other
0
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0
Figure 16: Shift Length Structure of Near Miss Department
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 17: Hours into Shift at time of NME 4.5 4 3.5 3 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
Figure 18: Time off before beginning of shift with NME 6 5 4 3 2 1 0 0-6 Hours
6-12 Hours
12-24 Hours
More than 24 Hours
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
Figure 19: Rank of Provider in Near Miss Department 6 5 5 4 3 2 1 1 0
0
0
0
0
0
0
0
0
0
0
Figure 20: Probablity of Reoccurence
Uncertain 33%
No 0%
Yes/ Probabiy 67%
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
#
Description
Lessons Learned/System Change
1
Event occurred on a Monday, 2 hours into the shift. Crew had just finished rig checks and their unit (truck 1) was placed "out of service" for maintenance. It was placed back into service approximately 1 hour later and approximately 15 m inutes after that a call went out. When the tones went off, there was confusion as to whether or not they were to take truck 1 or not. Meanwhile, a different unit was being serviced in the bay (bay 2) next to the responding unit (truck 1). The door for bay 1 was 1/3 of the way down. Maintenance personnel state that it was left that way to block the sun. The crew got into the unit, put it in drive and hit the garage door on the way out. They then backed in and switched units. All crews were fresh and coming on from days off. Communication was impaired due to crewmembers and maintenance personnel feeling frustrated at the unit status. Crew was responding code 3 to the call.
Crews need to be aware of their surroundings. Need better communication about the unit status. Crews need to maintain positive attitude and/or not let their anger get the best of them.
2
At 0844 hrs. this date, [agency] unit 301 was dispatched to [number] [name] Street in [city]. [City] FD on-‐scene. Law Enforcement responding. No indicators about staging passed along, and [agency] personnel were directed inside by FD personnel. Paramedics found an adult female who was passed out. Initial resuscitation efforts were initiated. Shortly after the initial [city] PD officer arrived on-‐scene. He began questioning the other 2 females. [Unit number] crewmembers had finished their initial patient care and were making preparations to get the patient to the ambulance. [A second] unit arrived on-‐scene. The crew made contact with the [second] patient. I gave them a short patient report and they were obtaining the initial vital signs when the officer indicated that he was going to leave. We were there with the [other] female and just getting her ready to leave the residence, when she stated she could not leave “because of the baby”. The Paramedics both looked at me, and I looked at the patient, and we all asked her what she was talking about. She stated that her 5-‐month-‐old granddaughter was in the “back bedroom”. We began looking for the infant. The female indicated that the “room” was in back, and the patient led [crewmember] back through the kitchen to a back bedroom. As the 2 of them entered that room, [crewmember] observed an adult male present, apparently sleeping. Paramedic [name] retreated back out to the living room area. As we were attempting to figure out what to do, one of the m ales came out of the back room and asked where the infant was. He became confrontational.
I immediately called [medical control] and requested officer’s return to our location. W e were in a bad situation. Two m ale subjects in a back room that we did not know were there, with no idea if they had weapons or not, in a residence where obvious drug issues were ongoing and at least one party had already been arrested for an unknown reason. Sometime later, the same officer that had been the initial officer arrived, and he came in and began questioning the two males. It was about that time that the infant’s father arrived on-‐scene, after being called by one of the females. He came in through the back door and was talked to by the officer. After that, he came into the living room area and the infant was left in the care of him and the [city] PD officer on-‐scene. I went out with [unit]’s crew when they moved their female patient out to the ambulance for transport. 1. Law enforcement should have cleared the entire house prior to departing. 2. Law enforcement should not have left the location prior to EMS departing, but they did. 3. Once confronted with the prospect of the 2 unknown m ale subjects, EMS personnel should have simply left the scene and awaited the re-‐arrival of law enforcement. Due to the circumstances and the young infant present, EMS personnel elected to wait for law enforcement to return, taking what precautions they could. Better communications with law enforcement. Change in radio communications. This system currently has only one radio frequency that allows communication between the EMS units and the primary dispatch center.
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E.V.E.N.T. Near Miss Report
THIRD QUARTER 2013
#
Description
Lessons Learned/System Change
3
While Responding to a cardiac arrest patient, [we] were met outside of a residence by an elderly male (spouse of the patient). He presented 2 DNRs for the patient, neither of which was valid. The first was missing the physician signature, and the second only had the physician signature (not patient's or witnesses {if the two papers were "married" together they would have been complete}). We explained to the man that they were invalid and we could not legally honor them. We explained politely that we would need to begin resuscitation and we would immediately consult online medical control, to cease efforts, as it was apparent those were the wishes of the patient and the family. We walked into the house where there was the patient's daughter as well. We again explained to them the entire way to the back bedroom where the patient was. On patient contact, I completed a primary assessment and found the patient to be pulseless and apneic. She met our criteria to begin resuscitation. I was next to the left side of the patient and the husband was to my right, standing very close to me. I started CPR on the patient, while I waited for help to move her to the floor. The husband became visibly upset about me starting efforts, and became very emotional. He began yelling "no", and attempting to push me out of the way. He threw his body onto the bed to cover his wife (in an effort to stop me from preforming compressions). A t this time, my partner was attempting to call OLMC to obtain an order to stop resuscitating. The patient's daughter was also becoming very upset and yelling. Other responders were positioned in a line next to the bed, they were all to the left of me. The patient's husband and I were standing next to each other and my arms were wrapped around his body, (in an effort to move him out of the way). He managed to get an arm loose and reached into a dresser drawer, and pulled out a .357 revolver (gun) out of it. I, luckily, immediately saw this, while he was sweeping the gun towards the responders. I grabbed his right hand, and tackled him onto the bed. Once I had his right hand (the one holding the gun) I shoved it into the crack between the head of the bed and the wall (under the headboard), in case the gun discharged, it would be down and away from the responders. After tackling the husband onto the bed, I was able to wrestle the gun out of his hands. My partner activated the emergency ID button on our Motorola radios (which kicks everyone off of the channel, and automatically keys up our mics, and broadcasts what it hears. (This is a safety feature they have).
My partner yelled something to the effect of "put down the gun". I handed the loaded gun to a Firefighter, to unload and secure. The man was then "secured and escorted" by members of the Fire Department, and we resumed the resuscitation, after moving the patient onto the floor. We immediately resumed our call to the online medical control and received an order to cease resuscitation, as previously attempted. As part of our dispatch protocols, commanders are automatically dispatched to Cardiac Arrest calls, so our responding commander heard this on the tactical channel we were previously assigned for our scene call (being assigned a certain tactical channel is standard for us). Pushing this Emergency ID button automatically generates a Code 3 response by Police department as well. The total time of this event (from m aking patient contact until husband was removed from the room) was well under a minute. We were incredibly LUCKY in this event. This event underlines the importance of situational awareness and scene safety. Keeping strong situational awareness and recognizing a VERY RAPIDLY escalating situation were two things that kept someone (probably a responder) from being shot, and probably killed. My partner and I have reviewed this call many times and believe the root cause of the issue was poor DNR education. If the family had a properly completed DNR this MIGHT not have ever happened. This is just an extreme example of this. Incomplete or not properly formatted/completed DNRs are a very common problem we run into in m y system/state. The law regarding resuscitation efforts with incomplete DNRs is very black and white. My Chief and other administrative staff are now working on a public Education Campaign regarding DNR education. This will be available publicly and to physicians in the county we respond in.
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E.V.E.N.T. Near Miss Report # 4
5
6
Description
THIRD QUARTER 2013
Lessons Learned/System Change
Crew was dispatched to the scene of a car wreck Better training for the Dispatch center where shots were being fired and the dispatcher told the P.D and the F .D., but not the EMS Crew. On the day in q uestion the u nit was coming back from a routine transfer to a nursing home when the driver veered off the on ramp and collided with 5 signs. The damage that occurred was damaged bumper, p unctured tire side wall, and b ox damage While transporting a patient to the pediatric trauma center non-‐emergent, the entire electrical system shut down and the ambulance stopped running in heavy traffic. Truck had enough momentum that we were able to cross a line of Interstate traffic and stop on the side of the road. A backup truck was called and completed the transport. Since this was n ot a critical patient, no adverse affect on patient outcome occurred. During shift change inspection, nothing unusual was noted and truck operated normally during the emergent response to the initial call and through half of the transport. The failure occurred while in slow moving traffic with less than a minute warning from sudden reduction in electrical activity in the truck to complete loss of power. The truck was towed to the repair facility where a defective alternator was found and replaced. The alternator had b een replaced [the previous] month, which indicates that the unit may have been defective at time of replacement. Given the circumstances, we can only be thankful this was not an emergent transport where there could have been a bad outcome for the patient.
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