Free and Secure Incident Reporting Systems for all Emergency Medical Services

i Apr 7th No Comments by

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 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, 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:

4Q2014 Patient Safety Summary

CY2014 Patient Safety Summary

CY2014 Near Miss Summary

4Q2014 Provider Violence Summary

CY2014 Provider Violence Summary

Please consider helping CLIR advertise the availability of the report by pointing your colleagues to If you would like to receive emails of all reported events send an email to 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.

For more information about EVENT or EMERG please visit or contact Matt Womble or Gary Wingrove.


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A State Partnership for Medicaid Managed Care Expansion (L. Davis)

i Feb 12th No Comments by

A State Partnership for Medicaid Managed Care Expansion (L. Davis)

Lisa Davis Pennsylvania December 2013

i Dec 4th No Comments by

Lisa Davis joined the Pennsylvania Office of Rural Health (PORH) in 1994 as its first full-time staff person. After a two-year hiatus, she came back to PORH in 1999 to serve as the director, a position she still holds. She is co-chair of the NOSORH Policy Committee, serves on the Awards Committee and was an inaugural member of the Educational Exchange Committee.

What do you like most about being a SORH director?

Acting as an advocate has always been an important thing for me. Right out of college, I worked in a residential program for schizophrenics and also volunteered for 15 years or so in the county prison. So, trying to address the needs of vulnerable populations is a priority for me. When I came to work for the state office, I met this amazing network of people in the state and across the country. I had never imagined there was a group so smart and so dedicated to what they were doing–and so fun. It was like finding this family that I hadn’t known was out there.

What skills do you think a SORH director needs?

Having a firm understanding of the issues–a good framework about rural populations. Having good interpersonal skills. Having vision for what you think should and could happen. And knowing what you know–and what you don’t know. There are so many tremendous resources out there. At any given time, I have 50 or so people I can call, either in the state or SORHs and other
rural contacts across the country, or others I’ve worked with. And I hope that I am a source of information for new folks coming up through the ranks. But I do have to say that there are many days when I realize that even with all the experience I have, there are others out there who know a lot more than I do. I’m always impressed when I get other peoples’ perspectives on things.

What are your goals for PORH next year?

* To continue to increase our relevance in rural health efforts in Pennsylvania. We are getting mini-grants out to communities, which is one way that we can help provide support for local projects.

* To establish a statewide rural health branding and marketing campaign to highlight why strong rural healthcare delivery systems matter. We’ll be presenting plaques with a logo we’ve had designed, which promotes rural health as high quality health close to home. [See design, below right]. We’ll be holding events at rural hospitals, rural health clinics, and other community-based
providers, presenting the plaques to recognize them as quality rural health providers. This way we can help build awareness that rural health is unique–and special.

* And, to continue to increase and diversify our funding, using ideas from our great Educational Exchange program with Graham Adams this year.