Safety advances have been broadly implemented in many healthcare settings, similar to aviation and other high-consequence fields. Aviation, with its long history of reporting systems, has shown that event reporting systems can yield previously unknown, but safety-critical information for developing a proactive approach to managing human error. Despite many similarities between health care and aviation, event-reporting systems have not been well received in health care. (AHRQ. Advances in Patient Safety: Vol. 3 – Identifying Barriers to the Success of a Reporting System. Michelle L. Harper, Robert L. Helmreich) According to this report, some physicians are still reluctant to participate in event reporting, and it is as difficult for Emergency Medical Services (EMS) professionals; however, this is exactly what the The Center for Leadership, Innovation, and Research for EMS is trying to change.
The Center for Leadership, Innovation, and Research for EMS (CLIR) is a non-profit organization that is advancing the safety culture in EMS through a variety of efforts. EMS safety must include responders, patients and members of the public. The ultimate goal is to help organizations create an environment that encourages individuals to report mistakes by using a method that has proved to work in the aviation industry.
Based on the Pennsylvania State EMS Event Reporting system, CLIR developed a national event reporting system for EMS called E.V.E.N.T. (EMS Voluntary Event Reporting Tool). E.V.E.N.T. is an anonymous, event-reporting system that collects and analyzes patient safety incidents, near-misses and violence against paramedics and EMTs. This gives any EMS system a free and easy way to identify trends and share information across regions.
Anyone involved in EMS systems can go to www.emsEVENTreport.com and submit one of three different kinds of anonymous reports.
- Patient Safety Event where a patient was harmed, potentially harmed, or almost harmed (“near-miss”) due to a human error or equipment failure.
- Near-Miss Event where an EMS provider (first responder, EMT, paramedic, etc.) was almost harmed but due to a fortunate break in the chain of events injury, fatality or other harm was averted.
- Violence Event where an EMS provider is struck, verbally abused, or otherwise assaulted.
Once submitted these anonymous reports are reviewed by EMS safety experts who remove any identifying elements and then share the report with the state EMS office in which the event was reported to have occurred. The state name is then removed and the record is shared through the E.V.E.N.T. Google Group and kept for a summary report. The data collected is used to develop policies, procedures and training programs to improve the safe delivery of EMS. The confidentiality and anonymity of this reporting tool is designed to encourage EMS practitioners to readily report EMS safety events without fear of repercussion.
CLIR wants to support organizational culture that is able to receive information about someone making a mistake without punishment. They want to help EMS providers become more engaged as healthcare providers instead of just being seen as “ambulance drivers.” E.V.E.N.T. was launched five years ago and has helped identify issues, learn from them and then help others across the country take steps to make sure it doesn’t happen in their system.
CLIR recently posted 4th quarter 2014 and calendar year E.V.E.N.T. summary reports. You can access these reports and prior period reports by going to www.emseventreport.com, click on each EVENT type at the top and then look on the left side of the screen for download links by year. To access the 4th quarter and calendar year 2014 reports individually without navigating the website, use these links:
Please consider helping CLIR advertise the availability of the report by pointing your colleagues to www.emseventreport.com. If you would like to receive emails of all reported events send an email to firstname.lastname@example.org with your name and EMS agency or affiliation and you will be added to the distribution list.
If you are interested in building a reporting site specific to your organization CLIR can help through it’s Patient Safety Organization (PSO) called EMERG. The Emergency Medical Error Reduction Group (EMERG) helps organizations use identified, non-anonymous data to drive improvement and advance their own safety culture, protecting patients and providers. All information collected is protected under federal law (“The Patient Safety and Quality Improvement Act of 2005 (PSQIA)), ensuring that the collected and analyzed incident data is not legally discoverable, above and beyond your existing state peer-review protections.