EMS Patient Safety Event Report - EMS Voluntary Event Notification Tool

FIRST QUARTER 2016

EMS Patient Safety Event Report 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 the first quarter of 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 Patient Safety E.V.E.N.T. summary report for first quarter 2016.

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

Patient Safety Event Reports Sorted Quarterly 2013

2014

Jan - Mar

31

30

19

Apr - Jun

39

29

18

Jul - Sep

35

24

12

Oct - Dec

32

30

4

Total

136

117

53

EMS Patient Safety Event

FIRST QUARTER 2016

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 .

2015 2016 14

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E.V.E.N.T. Report Completed Online

CLIR Notified of EMS Error

Quarterly/Annual Reports Generated

When an anonymous EVENT 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 Canada 0

United States 14

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0 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

ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO

E.V.E.N.T. EMS Patient Safety Event Report FIRST QUARTER 2016

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

16

14

12

10

8

6

4

2

Thanks to the Minnesota 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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FIRST QUARTER 2016

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Year Reported Patient Safety Event Occurred 16 14 12 10 8 6 4 2 0 2014

2015

FIRST QUARTER 2016

Month of Reported Patient Safety Event 9 8 7 6 5 4 3 2 1 0

2016

Role of Person Reporting Incident 16 14 12 10 8 6 4 2 0

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FIRST QUARTER 2016

Involvement in Safety Event 14 12 10 8 13

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Some of the reporters from this period are “not directly associated to the event”. The EMS system administrator dominates the “not directly associated” group.

4 2 0

1 0 Witness to the Incident Directly Involved with or Event Incident or Event

Not Directly Associated to Event

Category of Event

The events reported this period occurred in the medical treatment, disposition and transportation phases.

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Equipment Failure/Problem

Medication

Procedure/Operations

Clinical Judgement or Human Error

Judgement/Human Error

Training

Dispatch/Response

Vehicle/aircraft

12

10

8

6

4

Other

Patient died as a result of the event (sentinel event)

Patient experienced harm as a result of event

Near Miss- Event did not affect individuals or equipment, but had potential to harm

9 8 7 6 5 4 3 2 1 0

Unknown if patient experienced harm as a result of event

Medical Control/Protocol

E.V.E.N.T. EMS Patient Safety Event Report FIRST QUARTER 2016

Type of Patient Safety Event Equipment failures dominated the type of event, followed by medication error, clinical judgment, training and operations.

2

0

Patient Result of Patient Safety Event 8

3

1 2 0

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E.V.E.N.T. EMS Patient Safety Event Report # 1

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FIRST QUARTER 2016

Summary of Safety Event Reported

Summary of EMS Provider Opinions on the Cause of the Safety Event and their suggestions for mitigation At the start of a shift, the ambulance was missing some Lack of 2 systems or processes: 1. A system-wide and medical equipment including their cable for the CO sensor. standardized method to identify when equipment is The crew responded on a non-emergent call before they missing from a vehicle; 2. Establish clear roles and were able to obtain replacements. The crew had no responsibility for replacing missing equipment among crew SpO2/SpCO sensor for a 14 y/o patient to test for CO members. exposure. The response and concern turned out to be unfounded as the local FD discovered no carbon monoxide Standardize a method and tools used to more clearly mark exposure and only a faulty detector battery at the patient's when any ambulance is missing any patient care residence. The patient was not in need of any care or equipment. transport & it resulted in no harm. When removing a stretcher & patient in the hospital The slight uphill slope of the hospital garage and the wet garage, the safety catch bar did not engage floor hook and floor from snow likely contributed to the operator not the stretcher dropped about 2 feet before landing upright. controlling the removal procedure. It moved too far to the The patient had minor complaint of knee pain likely due to right and the weight and momentum combined to not impact with buckle on strap. No injury to crew members. allow them to pause to allow the wheeled carriage to be lowered and locked before the loading wheels came off the floor. They failed to adapt their removal procedure to those conditions. The crew likely tried to move too fast and did not allow time to interact and communicate about the status of the safety catch bar alignment with the floor hook. Slow down the stretcher/patient removal process and ensure that all steps, designed to prevent these events, are completed. Require that the stretcher manufacturer redesign the equipment to be safer. After placing a patient onto the powered stretcher, and The stretcher maintenance vendor found that the battery before moving to the ambulance, the controls had failed and was replaced. There was no apparent malfunctioned & continued to elevate it to the highest problem identified with the electrical switch position even when the raise button was components. Secondly, the manual height release lever released. Because the stretcher remained in the highest linkage needed bolt tightening and adjustments to make it position & would also not manually release to be lowered, functional. the patient had to pivot off the stretcher & ambulate to the jump seat in the patient compartment for The vendor was not completely confident that the faulty transport. The patient was transported sitting and this battery replacement was the only contributor to this event position, and having to ambulate again, slightly aggravated and will more closely monitor this stretcher for future their nausea and vomiting requiring additional treatments similar problems. with IV access and Zofran administration. The stretcher was left at the scene and later found to have several The manual release mechanism, found out-of-adjustment, maintenance needs. may need to be periodically checked as part of routine inspections since it is seldom actually used yet is vital that it be an available back-up system.

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

Summary of Safety Event Reported

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When attempting to acquire a 12-lead ECG in the ambulance, the screen indicated a "V-2 Lead Off" error message & appeared multiple times, even after changing the V-lead cables. Thus, they were unable to acquire a 12lead. The ECG rhythm was A-fib & there was no harm to this stable patient, later determined to be having anxiety related S&S, not a primary cardiac event..

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While transporting on a ground hospital transfer with a critical care team, the ventilator was alarming "Low O2 Pressure." After the run, it was discovered the main vehicle O2 tank regulator setting was off calibration reading 30-35 PSI when it should be 50-55 PSI. No harm to the patient since the ventilator continued to function and SpO2, EtCO2, and StO2 values remained in normal ranges. The ventilator required a minimum of 40 PSI and a maximum of 88 PSI to fully function. While attempting to administer a total of 324 mg chewable aspirin (ASA) to a chest pain patient, the supply found in the vehicle included only 1 tablet of chewable. The other ASA found was coated enteric. The patient was thus only administered 81 mg when the guideline called for 324 mg. This event was sored [sic] as no patient harm as it was later determined to not be a cardiac event.

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When attempting to initiate CPAP, the first disposable device package opened was discovered to be an incorrect configuration of the product. The crew had to open other packages to assemble all the necessary parts. This caused a slight, several minute delay to initiating CPAP. No patient harm resulted from this delay.

FIRST QUARTER 2016

Summary of EMS Provider Opinions on the Cause of the Safety Event and their suggestions for mitigation The failure to acquire a 12-lead was due to a main pt. ECG cable failure, not the V-leads. Testing later determined a wire break somewhere in the proximal end near the large plug where most of similar failures occur. It is known that this cable is prone to damage and failures due to hard use in the pre-hospital environment and bending it to fit into the storage case provided. A redesign of the cable to be more durable for EMS use and a better method for cable storage would reduce frequent, similar cable failures. The regulator PSI setting had changed for unknown reasons since it was checked and determined to be in range just 9 days earlier. Periodic checks of main O2 tank regulator for PSI output should be part of the ambulance equipment inspection routine and recorded on a checklist. This is especially important for services that use ventilators or other equipment with specific minimum PSI requirements. The wrong ASA type had been placed into the medication bag. There were multiple contributors. 1. Whoever restocked had not noticed that they had obtained from the hospital Pixis pharmacy dispensing system the enteric coated type of ASA. 2. The individual foil packaging of both types was very similar in appearance for size and color as well as both were 81 mg doses. 1. A basic patient safety behavior or practice for providers comes to mind here - pay attention to detail. 2. More frequent checking of the medication bag for correct contents might have caught the restocking error. The disposable supplies shipped to this ambulance base facility were the incorrect part and skew number. Several factors contributed: 1. The plastic bag container of the incorrect supply was very similar in size, color and overall appearance. There is a considerable amount of text information and symbols on the outer packaging with long complicated serial numbers. At a quick glance, the provider is simply looking for the correct size and assuming the other contents are correct. 2. The party who received and checked-in the shipment did not notice that it was the incorrect part and serial number. 3. Without opening the package, it is difficult to detect that the product is not the correct configuration. As with all best practices related to patient safety, attention to detail is important even before any product is stocked in the vehicle for potential patient use. The

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During the loading of a stretcher at a scene with the patient supine, the safety catch bar did not engage the floor hook & moved backwards resulting in a dropping of the patient back out of the ambulance of about 3 height levels before it stopped & locked. The stretcher landed upright on the ground & there is no reported harm to the patient or injury to the crew members.

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When attempting to chemically sedate a combative 89 y/o patient with a history of dementia, a medication error occurred related to the supplied concentration of lorazepam (Ativan). The intended dose was 1 mg and the actual administration was 2 mg. The vial concentration was 4 mg in 1 mL and the medic thought it was 4 mg in 2 mL. No harm to the patient for which the 2 mg dose was still within an acceptable dose range and there were no untoward effects. After a dose of lorazepam (Ativan) was administered IM to the left deltoid, transport resumed. On arrival at the hospital, after 13 minutes en route, the patient was much less agitated and resistant. By the time the crew cleared the hospital, the patient continued to be calmer and did not require physical restraints.

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When administering diltiazem (Cardizem) for atrial fibrillation with RVR, the concentration available in the vial was misread & the patient was under-dosed. The medic used a weight-based calculation using 25 mg/1 mL as the concentration (0.8 mL given) when the actual concentration was 25 mg/5 mL. The dose should have been 20 mg and they actually delivered 4 mg. Regardless, the patient's A-fib converted en route 5 min. after administration to a normal sinus rhythm, rate in the 70's and resolved the hypotension. The 12-lead ECG interpretation even improved. The desired affects were achieved with the under-dose and with no patient harm.

FIRST QUARTER 2016

manufacturer might consider different appearing packaging to help more easily distinguish among products which have different sizes and configurations. Multiple contributors were identified: 1. The crew rushed the loading procedure and did not observe if the safety catch bar engaged the floor hook before proceeding. 2. The crew did not verbally communicate if the hook had engaged the safety bar or not. 3. The safety catch bar was moving stiffly and not returning to a complete vertical position due to needing bearing lubrication. Suggestions: 1. Slow down and do not skip steps in the loading and unloading procedure, including active communication between the operator and assistant. 2. Assure that the safety catch bar is always returning to the correct position. There are a number of conditions and circumstances that can interfere with the function of that stretcher component. The primary error was not reading the Ativan vial label to see the correct dose weight per mL Then, the other crew member did not challenge the medic when the concentration was stated incorrectly. If all steps of the medication safety check had been followed, this simple error may have been prevented. This was partially an action error based on non-compliance with the drug administration procedure and relying on memory rather than reading the concentration on the vial. For patient and provider safety, the patient should have had the Posey restraints applied at least to her wrists. Having to manually hold the patient during the attempted chemical sedation administration process created a distraction and contributed to the medication error. Require compliance with the medication safety check procedure between providers before any administration. The 1st human error in this event was related to misreading the vial and using that information in the dose calculation. In human factors analysis, this is a classic “perceptual error” of the “confirmation bias” type. The medic read it as what he was expecting it to read rather then what was actually written. An examination of the vial used reveals that the concentration is clearly labeled. A 2nd error was shared by both crew members in that they did not correctly engage in a medication safety check procedure designed to prevent or discover exactly this kind of error. This was an action based error when they failed to follow a verification process. Not performing the complete medication safety check, and recognizing this is a

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required procedure in the protocols & clinical guidelines, borders on “risky behavior”. FIRST QUARTER 2016 E.V.E.N.T. EMS Patient Safety Event Report All EMS systems should consider additional education and information about the importance of and required use of their medication safety check procedure. This service requires a confirmation of the vial concentration and corresponding mL to be delivered between the providers before administration. While attempting to raise up the height of a patient the The cause of the mechanism failure was never stretcher, the foot-end release handle did not release the determined. Testing of the stretcher was done and found wheeled carriage and allow it to descend. It took 3 to have no maintenance or repair needs and functioned attempts of lifting the stretcher with a 3rd person having normally. It is possible that the operator at the controls to grab the framework and applying manual force to reach was not totally familiar with how to properly operate the the transport height. Then, the release control handle mechanism combined with the 288 lb. weight of the again failed when attempting to load into the patient an additional consideration. ambulance. The patient was jostled and feared he was going to tip on the stretcher. No patient injury. The crew should use additional assistants when moving a heavy patient. In a hospital garage, the crew was loading a 130 lb. patient The foot-end operator failing to follow proper loading into the ambulance on the stretcher. The foot-end procedure and coordinating his actions with the other operator did not push the stretcher in far enough the allow crew member. They did not confirm that the safety catch the safety catch bar to engage the floor hook. When he bar was indeed engaged with the floor hook. On later lifted the foot-end off the ground and released the inspection, there were no maintenance needs for this carriage, the stretcher dropped back out and dropped stretcher. about 1/2 way to the ground before catching on and stopping at the folded up step bumper. The patient nor Slowing down the stretcher loading procedure and the crew were not injured. following all steps, including the communication needed between operators. While attempting to acquire a 12-lead ECG, a V-3 lead The patient ECG cable supplied by the cardiac monitor error message appeared for 3 attempts and the crew was vendor is not durable enough for repeated prehospital unable to complete the assessment. The cause was later environment and fails often. The problem was a faulty determined to be a faulty main patient ECG cable. No wire that runs through the main cable near the proximal harm to this patient who was later determined to not be plug. experiencing a major cardiac event or needing cath-lab activation. The manufacturer should provide a more suitable cable set that stands up to the rigors of the prehospital environment. After and IV was established, 50 mL of D-50 was Not verifying that the IV site is patent prior to D-50 administered. It was determined within a few minutes administration and not monitoring the IV site for after the administration that to IV site was infiltrated & the infiltration during administration. The D-50 was likely also D-50 was in the extra-vascular space. The extent of local pushed too fast and not titrated to the patient's response. tissue damaged was unable to be immediately determined. The D-50 was again administered thru a The reporting medic sited that a new type of IV catheter newly established IO site. which contains a one- way valve prevented them from checking patency. This is not an issue or a contributor if the crew checks for patency after connecting the IV tubing. The providers need to be more certain that the IV is patent before administering any medication, especially D-50 which will cause localized tissue damage.

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FIRST QUARTER 2016

Notice/disclaimer: all manufacturer and model names are removed from this document because EVENT is an anonymous system. The anonymity of EVENT reports is protected and the reporter cannot be verified as a neutral party trained to provide a fair and unbiased assessment of the events or product usage. For this reason we redact all names, including the manufacturer and model. We operate another reporting system, the Emergency Medical Error Reduction Group (EMERG), which can provide states or individual EMS agencies a non-anonymous error reporting system. As a designated Patient Safety Organization (PSO), EMERG has federal discovery protection for all information entered and analysis completed. EMERG can help identify actual manufacturing issues and partner with industry to correct issues and thereby improve the culture of safety in EMS. For more information please about EMERG, contact Matt Womble, MHA, Paramedic, Director of EMERG ([email protected]). (EMERG is federally designated as PSO # P0133 by the U.S. Department of Health and Human Services, Agency for Healthcare Research & Quality.) 12