Patient Safety in Emergency

Medical Services
Ontario Base Hospital Group Annual Symposium
May 15, 2013
 Canadian Patient Safety
Institute
Our Vision:
Safe healthcare for all Canadians
Our Mission:
To inspire extraordinary improvement in patient safety and
quality
Our Main Roles:
• We champion the cause of patient safety.
• We help create the capacity to improve.
• We are integrators; brokers; catalysts; and promoters.
• We create resources for the healthcare system, work with partners, and
celebrate successes.
• We listen, engage, customize, and spread knowledge.
Our Mantra
 Definitions

Patient safety – the avoidance, prevention, and

amelioration of adverse outcomes or injuries
stemming from the processes of health care
• Patient safety incident – an event or circumstance that could have
resulted, or did result, in unnecessary harm to a patient
• Harmful incident (preventable adverse event) – an
incident which resulted in harm to a patient
• No harm incident – an incident that did reach the patient but
did not result in harm
• Near miss – an incident that did not reach the patient
• Reportable circumstance – a situation in which there was
significant potential for harm, but no incident occurred
Preferred Terms

Adverse
Healthcare Events
Harmful
Associated Harm
Incidents Patient Safety
No-
H iss
Incidents
Inci arm r- M
den Nea dents
ts
Inci

Reportable Circumstances
 Definitions

Adverse event defined as:

“an unintended injury or complication that results
in disability at the time of discharge, death or
prolonged hospital stay and that is caused by
health care management rather than by the
patient’s underlying disease process.”
Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J et al. (2004).
The Canadian Adverse Events Study: The incidence of adverse events among
hospital patients in Canada. CMAJ, 170(11), 1678-1686.

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Canadian Adverse Events
Study (Baker et al., 2004)
Findings:
• 3,745 charts reviewed
• ~7.5% of hospital admissions involve harmful
incidents (adverse events); 37% of these were deemed
to be preventable
Extrapolation:
• Of ~2.5 million hospital admissions in Canada in
2000…..
– 185,000 experienced 1 or more adverse events
– 70,000 of the 185,000 were determined to be preventable
– Between 9,000 and 24,000 deaths due to adverse events
could have been prevented
Canadian Adverse Events
Study

Deaths among patients Extra hospital days

with preventable adverse associated with
events adverse events
 Risky activities
15,000 deaths/yr
Dangerous Regulated Ultra-safe
(>1/1000) (<1/100K)
100,000
Total Lives Lost per year

Hospitalization
10,000
Driving

Offshore rig
1,000
Commercial airlines
Coal Mining
100 timber Firearms
truckers
Rock construction
10 Climbing Bungee Jumping
for 25 hrs Scuba diving

1 10 100 1000 10,000 100,000 1,000,000 10,000,000

Faceless statistics…

Vance’s passion for helping others lives on

Understanding the issues
 Many issues related to patient safety are
applicable throughout the care continuum
 CPSI has made a concerted effort to understand
these complex issues both within and external to
hospitals
 Community-based healthcare has additional
unique patient safety issues that must be
understood in context before they can be
appropriately addressed
 Background

As well trained, compassionate caregivers EMS

professionals often care for patients in unstable,
challenging and dynamic environments.
Providing care in this type of high stress atmosphere
means that well intended caregivers are at risk of
causing inadvertent harm to patients.
Little research has addressed the types and
frequency of patient safety problems during the
delivery of pre-hospital care.
Patient Safety in EMS
Three Part Project

Systematic Review of the Literature

“What do we already know?”

Qualitative Interviews with Key Informants

“What do we already think?”

Roundtable Event
“Where do we go from here?”
 Key Issues
 Clinical judgement and training
“Clinical judgment and the training required to make coherent
decisions was profoundly identified as the greatest risk to patient
safety”
 Focus on EMS and relationship to healthcare
“...EMS has shifted to the healthcare domain, however, true
integration with that system is lacking.”
 Vehicle collisions
 Medication incidents
 Knowledge gaps
“...there is a need to study best practices in educating paramedics
and to clarify what constitutes adequate clinical experience,
exposure and judgment.”
 Strategic Priorities
1. Make patient safety a strategic priority
2. Include patient safety domains in the NOCP &
paramedic curriculum
3. Create a web based reporting and learning
system
4. Support more EMS
research
5. Create standardized
definitions and
outcomes
 Strategic Priorities

6. Support the concept that the paramedic is part

of the healthcare team
7. Examine the literature from other disciplines
8. Build human resource capacity in EMS
research, education and patient safety
9. Promote the identification and reporting of
high-risk activities performed by paramedics
Key Themes

 The Need for Collaboration

 The Need for Enhanced Education
 The Need for Further Research
 The Need for a Cultural Shift
 Organization's structures and
control systems

“The way we do things around here”

Values Beliefs
Behavioural Norms

“Shared values (what is important) and beliefs

(how things work) that interact with an
organization's structures and control systems
to produce behavioural norms
B Uttal “The corporate culture vultures” Fortune 1983
 Culture of Quality and Patient Safety

GENERATIVE
Safety is how we do
business around here
Increasingly Informed
PROACTIVE
We work on the problems that
we still find

CALCULATIVE
We have systems in place to manage
all hazards

REACTIVE
Safety is important, we do a lot every
time we have an accident Increasing Trust

PATHOLOGIC
Who cares as long as we do
not get caught
 A Culture of Safety
31,033 Pilots, Surgeons, Nurses and Residents surveyed

% positive responses from: Pilots Medical

Is there a negative impact of fatigue on your 74% 30%
performance?
Do you reject advice from juniors? 3% 45%
Is error analysis system-wide? 100% 30%
Do you think you make mistakes? 100% 30%
Easy to discuss/report mistakes? 100% 56%

Sexton, JB, Thomas, EJ, & Helmreich, RL (2000). Error, stress and
teamwork in medicine and aviation: cross sectional surveys. BMI, 3(18).
 System Failures

CMPA

Funding & Organization Team Provider

Culture Shifting
Resources Training
Incomplete responsibilities
Distractions
policies Handovers
Fatigue

From J. Reason
The Systems Approach

“…though we cannot change the

human condition, we can change
the conditions under which
humans work.”

Reason J. (2000). Human error: models and management.

BMJ, 320(7237): 768-770,
High Reliability Organizations
• Preoccupation with
failure
• Reluctance to simplify
interpretations
• Sensitivity to
operations
• Commitment to
resilience
• Deference to expertise Weick & Sutcliffe, Managing the Unexpected, 2001
Systems thinking vs.
“blame-free” culture
 Systems thinking is not a “blame-free”
culture
 Emphasizes analysis of the entire system of
care
– instead of a rush to blame individuals
 People are part of the system
– disregard for professional responsibility is
grounds to hold an individual accountable
Just culture of safety

 There is focus on system, not on individual

 The organization accepts appropriate
responsibility and accountability
 The organization does not tolerate wilful
misconduct and misbehaviour
 There is “a collective understanding of where
the line should be drawn between blameless
and blameworthy actions”
Patient Safety Culture

“There is a culture in every health care facility. Often this

culture has more of an impact on patient safety than the
process problems that exist.”

“Changing the way people think about patient safety is not

easy. Culture change is not a program. By definition,
programs have beginnings and ends. They often are
directed at manipulating people in some way to achieve an
end result. They can even be punitive. Culture change is a
process that, once embraced by the people, brings about
lasting change.”

http://www.brownspath.com/original_articles/culture.htm
Canadian Patient Safety Officer Course

 Partnership with CPSI

and CHA
 4 day intensive program
designed to train patient
safety officers
 Geared to those with
roles in developing
quality and patient
safety programs
PSEP Canada

 Comprehensive
“accordian-style”
curriculum
 Modified for Canadian
context
 Team-based program
 Learn sample content
using various
pedagogical approaches
Summary

 To blame is human, but once you understand

that, you can guard against it using systems
thinking.
 Healthcare is a complex system of interacting
components. The interactions among the
components produce safety or a lack thereof.
 Empathy is a crucial part of our systems and
culture change agenda.
The Patient Experience

“…there are some patients we cannot help,

there are none we cannot harm...”

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Contact Information

Sandi Kossey, Senior Director

780.498.7252
skossey@cpsi-icsp.ca

Abigail Hain, Director of Education

613.738.4779
ahain@cpsi-icsp.ca

www.patientsafetyinstitute.ca

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