Slide 1 by A8217J2

VIEWS: 2 PAGES: 19

									Development of an EMS Patient
   Safety Reporting System

             Rollin J (Terry) Fairbanks, MD, MS
                    University of Rochester
                Dept of Emergency Medicine
                 Terry.Fairbanks@Rochester.edu




             AHRQ Patient Safety and HIT Conference
                        Washington, DC
                          June 5, 2006
    Acknowledgements

       Co-investigators
        –   Manish N. Shah, MD, FACEP
            Dept of Emergency Medicine, University of Rochester
        –   Howard Werman, MD
            Dept of Emergency Medicine, Ohio State University
        –   Robert Gwinn, DO
            MEPARS, Inc
       Research support
        –   NIH/NINR 1R41NR009592-01 (STTR)
       Conflicts of interest

2
    Overview

       EMS
        –   Background
        –   Challenges
       Brief introduction to event reporting
        –   Evolution from aviation
       MEPARS – event reporting for EMS
        –   Process


3
    Background

       Emergency Medical Services (EMS)
        –   Provide prehospital care
        –   EMTs: Basic Life Support, non-invasive
        –   Paramedics: Advanced, invasive procedures
                Much treatment as in ED
       Unique practice setting
       Often operate alone


4
    Background

       Approximately 25 million patients/year
        –   >1/10 Americans per year
        –   Similar to annual surgery rate
       Complex and high risk medical environment
       IOM: highest preventable adverse event
        rate in ED
        –   Consideration was not given to EMS (coming)
        –   EMS is most similar to the ED environment

5
    Challenges

       Unusual patient care
        environment
        –   Unusual locations
        –   Stressful situations
        –   Less backup
        –   Often alone
        –   Portable equipment




6
    System protections

       Hospital               EMS (often alone)
        –   Physician           –   Paramedic
        –   Pharmacist          –   EMT
        –   Nurse
        –   Tech
        –   Transporter
        –   Social worker
        –   Secretary




7
    EMS Adverse Events: Pilot Data

       15 in-depth interviews with paramedics
        –   All had multiple events to report
       Resulted in 61 event descriptions
        –   44% near misses
        –   56% adverse events
       Only 1/3 were reported to anyone
       Very little data on adverse events in EMS

    Fairbanks RJ, Crittenden CN et al. The Nature of Adult and Pediatric Adverse Events
    and Near Misses in EMS. Prehospital Emergency Care, 2005; 9(1): 102-103.
8
    EMS Defibrillator Usability Study

       Fourteen paramedic participants
       Four tasks: 2 routine, 2 emergent
       SimManTM patient simulator
       50% of participants defibrillated when they intended
        to cardiovert (on second shock)
        –   potentially fatal
        –   In many cases, participants were never aware
        –   All errors clearly attributable to poor interface design


    Fairbanks RJ, Caplan S, et al, Defibrillator Usability Study Among Paramedics,
    Proceedings of the Human Factors and Ergonomics Society Meeting. Sept 24, 2004.
9
     1st Step: Error Identification

        Must anticipate errors to design system
         protections
         –   Study near misses & adverse events
                 “Today’s near misses are tomorrow’s adverse events”
                 Event reporting systems
         –   Strong egos breeds secretive culture
                 “People who make mistakes are bad”
                 Punitive nature (peers, employers, regions, states)
                 No sharing of information between systems or agencies
                 Hierarchical structure predominates
10
     Example from Aviation: 1974

        United flight on approach to
         Dulles
        Misunderstood approach
         instructions
        Premature descent
        Narrowly averted flying into
         mountain
        Reported to internal system
        Alert issued to all United pilots

11
     6 weeks later (Dec 1, 1974)…

        TWA flight 514 crashed 25 miles from Dulles,
         Killing all 92 on board
        Investigation found same sequence of events
        FAA reacted quickly
        Aviation Safety Reporting System (ASRS)
         –   asrs.arc.nasa.gov




12
     Aviation Safety Reporting System
     (ASRS)

        Database of near misses/adverse events
        Key components
         –   Administered by NASA (third party), not FAA
         –   Incentive to report: immunity
         –   Anonymous
         –   Includes all players (pilots, mechanics, ATC, flight attendants
         –   Has become part of the culture
         –   Expert analysis and classification
         –   Data widely available
        Hundreds of system improvements


13
     ASRS




            asrs.arc.nasa.gov
14
     Event Reporting in Medicine

        IOM recommends reporting systems
        Failure of most in medicine
         –   No incentive, cumbersome
         –   Classified by end-user
        Model System: VA PSRS (NASA)
        Few EMS Event Reporting Systems
         –   Local system: Houston, others
         –   State System: Pennsylvania
         –   National System: MEPARS
15
     MEPARS

        MEPARS
         –   Medical Error Prevention and Reporting System
         –   Based on ASRS model
        University of Rochester Research Partnership
         –   NIH/NINR (STTR) Funding
         –   Rochester area agencies
         –   Data analysis
        Intent – make findings widely available
         –   www.mepars.com



16
                              Report
                             Received

     MEPARS                  MEPARS

     Process                 Screening


                         Clarification
                         Phone Call


                              Receipt          Identifiers
                             Returned           Removed

                               Case
                                               Data Entry     Originals
                             Analysis &
                                                              Destroyed
                              Coding


                         Disseminate
                           Results



Diluted Cases   Trends in           Journal Articles         Database
 on Website     Newsletter                                   Searches
     Conclusion

        EMS is a high-risk and commonly used
         medical environment
        Little is known about adverse events in EMS
        Non-punitive event reporting systems work
        No current event reporting standard in EMS
        MEPARS is one solution



18
     www.mepars.com


     Patient Safety
      is everyone’s
      responsibility
     RJ (Terry) Fairbanks, MD, MS
         University of Rochester
      Dept of Emergency Medicine




     Terry.Fairbanks@Rochester.edu
19

								
To top