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This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2022;26:492-502.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17:458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Cicero MX, Adelgais K, Hoyle JD, et al. Prehosp Emerg Care. 2020;25:294-306.
This position statement shares 11 recommendations drawn from a review of the evidence to improve the safety of pediatric dosing in pre-hospital emergent situations. Suggestions for improvement include use of kilograms as the standard unit of weight, pre-calculated weight-based dosing, and dose-derivation strategies to minimize use of calculations in real time.   
Donnelly EA, Bradford P, Davis M, et al. CJEM. 2019;21:762-765.
While fatigue has been linked to safety-related outcomes in many healthcare settings, this link has not been definitively established in paramedicine. This article documents preliminary evidence—based on 717 surveys conducted in ten paramedic services in Ontario, Canada—of a relationship between fatigue and paramedic-reported safety outcomes and safety-compromising behaviors. The authors recommend fatigue mitigation efforts. 
Hoyle JD, Ekblad G, Hover T, et al. Prehosp Emerg Care. 2020;24:204-213.
Emergency medical technicians (EMTs) often make dosing errors when administering medication to pediatric patients. This study found that in simulations, Michigan's state-wide pediatric dosing reference system reduced but did not eliminate prehospital provider medication mistakes. A PSNet perspective further explores prehospital patient safety.
Schewe J-C, Kappler J, Dovermann K, et al. Scand J Trauma Resusc Emerg Med. 2019;27:36.
In Germany, prehospital emergency response teams include physicians, but little is known about their performance with regard to diagnostic accuracy. In this retrospective observational cohort study, researchers analyzed diagnoses made by a German prehospital emergency medical service in 2004 and in 2014. For each patient meeting inclusion criteria, they compared the prehospital diagnosis with the diagnosis made in the hospital and found that diagnostic accuracy improved by more than 5% in 2014 compared to 2004.
Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.
This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.
Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
Erich J.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
Misasi P, Keebler JR. Ther Adv Drug Saf. 2019;10:2042098618821916.
This pre–post study reports a decline in medication error rates in prehospital emergency services following implementation of a human factors engineering approach. The providers implemented a team-based cross-check process using standardized communication for high-risk medications and found a significant reduction in medication errors.
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
Bohm K, Kurland L. Scand J Trauma Resusc Emerg Med. 2018;26:94.
Medical dispatch is charged with deciding the level of acuity of out-of-hospital emergency situations and deploying appropriate emergency services. This systematic review found very little evidence about the accuracy of medical dispatch at identifying cardiac arrest, stroke, major trauma, or the medical priority of callers. The authors call for standardized measures of dispatch accuracy to guide further research.
Center for Leadership, Innovation and Research; CLIR.
Emergency medical services harbor unique challenges to safe patient care delivery. This center serves as a patient safety organization for prehospital care providers, provides access to anonymous reporting tool, and hosts educational opportunities that support a culture of safety in the emergency medical services environment.
Boyle MJ, Eastwood K. World J Emerg Med. 2018;9:41-45.
Safe medication administration in the prehospital setting requires paramedics to rapidly and accurately calculate medication doses. Researchers tested 20 experienced Australian paramedics in a classroom and found that most made errors in dosing or arithmetic. In other studies, human factors engineering approaches showed promise in reducing reliance on mental math.
Meckler G, Hansen M, Lambert W, et al. Prehosp Emerg Care. 2018;22:290-299.
Few studies have characterized adverse events in emergency medical services (EMS), and even fewer have focused on children. In a chart review of all critically ill pediatric ambulance transports in Multnomah County, Oregon, researchers found that nearly 70% resulted in a patient safety event, 23% of which were severe. The authors call for improved EMS provider training in neonatal care and pediatric resuscitation.
Hansen M, Eriksson C, Skarica B, et al. Am J Emerg Med. 2018;36:380-383.
Adverse events in prehospital care are an increasing area of focus in patient safety. In this retrospective study, researchers examined the medical records of 35 out-of-hospital cardiac arrests among children younger than 18 transported by a single emergency medical services system. They identified a safety issue in 87% of cases and, similar to prior research, they found that medication errors were common.
Guise J-M, Hansen M, O'Brien K, et al. BMJ Open. 2017;7:e014057.
Prehospital emergencies are time critical, and they occur in uncontrolled and often challenging environments. Although emergency medical services (EMS) providers are known to experience high levels of stress, whether their stress contributes to patient safety problems is unclear. In this qualitative study, investigators analyzed perceptions of stress and safety in pediatric out-of-hospital emergencies. They identified factors that contribute to increased stress and therefore adversely affect patient safety, including provider sympathy for children and identification with children or family, which participants felt could cloud their clinical judgment, and lack of familiarity with pediatric emergencies, as seen in other clinical settings. This study highlights a need for specific pediatric training for EMS providers to enhance safety.