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Approach to Improving Safety
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Search results for "Active Errors"

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Journal Article > Review

A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics.

Alabdali A, Fisher JD, Trivedy C, Lilford RJ. Air Med J. 2017;36:116-121.

Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.

Journal Article > Study

Pediatric prehospital medication dosing errors: a mixed-methods study.

Hoyle JD Jr, Sleight D, Henry R, Chassee T, Fales B, Mavis B. Prehosp Emerg Care. 2016;20:117-124.

Medication errors are common in pediatric patients who require care from emergency medical services. This study found that most paramedics had limited experience and comfort in administering medications to children. Investigators identified several remediable barriers to improving medication safety in this setting.

Journal Article > Study

Managing competing organizational priorities in clinical handover across organizational boundaries.

Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Pol. 2015;20(suppl 1):s17-s25.

Patient handoffs are a major challenge for patient safety, especially when patients move between different units or organizations. Analysis of 270 handoffs between ambulances to emergency departments (EDs) and EDs to inpatient units uncovered many tensions and themes, such as how competing patient flow priorities can impact the quality of handoffs.

Journal Article > Study

Optimizing the patient handoff between EMS and the emergency department.

Meisel ZF, Shea JA, Peacock NJ, et al. Ann Emerg Med. 2015;65:310-317.e1.

This focus group study with emergency medical services personnel identified several potential ways to improve the quality of handoffs between paramedics and emergency department staff. A structured handoff tool has been developed to address this known safety hazard.

Book/Report

Strategy for a National EMS Culture of Safety.

Irving, TX: American College of Emergency Physicians; 2013.

This report explores risks associated with emergency medical services and describes how to implement a safety culture in this setting.

Journal Article > Review

Review article: improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient.

Dawson S, King L, Grantham H. Emerg Med Australas. 2013;25:393-405.

Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.

Journal Article > Study

Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.

Balka E, Tolar M, Coates S, Whitehouse S. Int J Med Inform. 2013;82:e345-e357.

This ethnographic case study explored patient handoffs across different situations, including pre-hospital and primary care settings. These analyses emphasize numerous contextual issues that need be considered when creating computerized systems to support handoffs.

Journal Article > Review

Disclosure of harmful medical errors in out-of-hospital care.

Lu DW, Guenther E, Wesley AK, Gallagher TH. Ann Emerg Med. 2013;61:215-221.

This review discusses barriers to error disclosure by emergency medical services providers and recommends tactics to help them communicate with patients.

Journal Article > Study

What causes adverse events in prehospital care? A human-factors approach.

Price R, Bendall JC, Patterson JA, Middleton PM. Emerg Med J. 2013;30:583-588.

Patient safety issues in prehospital care are receiving increased attention. This survey of Australian emergency services personnel used a human factors approach to characterize the underlying causes of prehospital adverse events.

Journal Article > Study

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.'

Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-633.

Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.

Newspaper/Magazine Article

Get a clue: it can be all too easy to make assessment errors in the field; here's some tips to prevent you from making mistakes.

Rubin M. EMS World. 2011;40:57-64.

This article describes how misdiagnosis can occur during emergency assessments due to bias, incomplete data, ineffective communication, and misinterpretation of results.

Journal Article > Study

Medication prescribing errors in the prehospital setting and in the ED.

Lifshitz AE, Goldstein LH, Sharist M, et al. Am J Emerg Med. 2012;30:726-731.

This study discovered that medication errors were more common in the emergency department setting than in emergency vehicles, and patients requiring multiple medications were at higher risk for medication errors.

Journal Article > Study

Communication errors in dispatch of air medical transport.

Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.

This study analyzed communication errors during call bookings for air medical transport and found both human and process-driven root causes. Examples of major errors identified were commissions of allergies to medications and omissions of intubations from records.

Journal Article > Study

Safety through redundancy: a case study of in-hospital patient transfers.

Ong MS, Coiera E. Qual Saf Health Care. 2010;19:e32.

This study examined in-hospital patient transfers and discovered poor compliance with existing safety steps designed to prevent errors. A past AHRQ WebM&M commentary discussed a death that resulted from unsafe intrahospital transport.

Journal Article > Study

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

This qualitative study found that while safety issues in pediatric prehospital care are not uncommon, most go unreported.

Journal Article > Commentary

Structured communication for patient safety in emergency medical services: a legal case report.

Greenwood MJ, Heninger JR. Prehosp Emerg Care. 2010;14:345-348.

This article describes a case where lack of clarity in communication contributed to the death of a patient and highlights strategies to prevent similar failures, including read back and critical assertion.

Cases & Commentaries

Missing Trauma

  • Web M&M

Gregory J. Jurkovich, MD; May 2009

After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.

Newspaper/Magazine Article

Reportable incidents.

Barishansky RM, Glick DE. EMS Magazine. 2009 Mar;38:43-47.

This article explains the elements of preparing policies and procedures for reportable incidents in emergency medical services.

Newspaper/Magazine Article

No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.

Rajasekaran K, Fairbanks RJ, Shah MN. EMS Mag. 2008 Sep;37:61-67.

This article describes how applying a just culture and systems approach to adverse events may help change the "blame-and-shame" mentality in emergency medical service provision.

Journal Article > Study

Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. 

Fairbanks RJ, Crittenden CN, O'Gara KG, et al. Acad Emerg Med. 2008;15:633-640.

This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.

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