Proper Steps to Take?
OK so you’ve made a mistake during a call. What do you do now? Photo DNY59/iStockphoto.com
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Few of us who have been in EMS for any period of time can claim that we have never made a mistake...and frankly, those who do are being less than circumspect. What are our legal and ethical responsibilities to report medical errors? Can we let fear of punitive actions from our employers impair our ability to do what is right? What should we do if we make a mistake?
Medication errors are more common than you think. Despite the "red box, blue box" mentality in EMS, we work in difficult environments that are extremely stressful and often not well lit. A medication error may—and may not—result in harm to a patient. A vasopressor drip that gets loose, a decimal point that is one number off—all can result in an adverse outcome to a patient. There may be other errors as well; with patient assessment errors leading the pack to erroneous treatment in the prehospital setting. Not all of the care we provide falls into the category of "benign" treatment and there may be long term sequelae for patients as the result of what we do early on in an emergency.
Reporting
EMS providers haven't evolved to a point where we grasp our responsibilities to report medical errors as well as physicians do. A 2002 study published in Prehospital Emergency Care contained a consensus statement that standard operating procedures to prevent and recover from medical errors in the field are "in their infancy."(1) A 2006 study done at the University of North Carolina at Chapel Hill indicates that EMS providers demonstrate the capacity to identify, report and, to a lesser extent, disclose errors in hypothetical scenarios. However, the study further found that EMS may not apply these skills uniformly in their own practices, and that there's a need to enhance error management skills in prehospital clinical practice by focused education and training.(2) "As is reflected in the Just Culture movement, to err is human. Most medical errors occur not as a result of malicious intent but more to flaws in the system that permit the error to occur," says Keith Wesley, MD, medical director for HealthEast Ambulance in St. Paul, Minn.
The Firefighter Near Miss website provides us with an interesting paradigm of learning from mistakes. Those who managed to survive an error in firefighter judgment publicly report their mistakes so that others can benefit from them. However, in EMS patient care we hesitate, probably because of fear of retribution in the form of employment consequences we can't afford, or due to fear of lawsuits.
So, what do you do if you've made a mistake? Hopefully, you're working in an EMS service that promotes high-quality patient care, which is synonymous with a non-punitive, peer-review environment. Regardless of the type of system you work for, you should report a medical error as soon as you know about it: to your supervisor, to the receiving ED when you bring in the patient and to your own medical director. Unfortunately, few EMS services have any clinical guidelines for reporting of medical errors and providers are often left without any guidance, wondering what to do.
What NOT to Do
Even though it might be hard to determine what to do, there are a few universal don'ts.
What don't you do? EMS providers should not take it upon themselves to report errors directly to a patient without consultation first. Disclosure to a patient that they have been harmed by EMS error is a delicate situation requiring the involvement of the service administration, medical director, risk manager and legal counsel.
Telling a patient what happened, and why it happened, and what is being done to prevent it from happening again is the heart of full disclosure, and what patients want to hear. Honesty and empathy are important elements of disclosure. However, the timing of disclosure may also be important, as it may be best to wait until a patient has recovered from a significant adverse event before discussing the issue directly with them. When the patient is a child, the family must be involved and emotions may run high. It's important to word a disclosure correctly, and to not place blame on others.
What else don't you do? Hide it, lie about it, delay in reporting it or deny it. Nothing will anger a jury more than hearing that not only was a mistake made, but that "they tried to cover it up." But don't confess directly to the patient—at least not initially. The handling of disclosure of medical error to a patient is fraught with legal and ethical landmines, and should be handled within your EMS system and with the guidance of your medical director, administration and risk manager. Most services have a separate "incident report" for charting of unusual circumstances, equipment failures, on-scene problems, or medical errors. Charting should be complete and accurate, but it should contain only facts and not opinions.
Conclusion
If you witness an error committed by another provider, you still have an obligation to report it. Again, this should be accomplished in accordance with your service's clinical guidelines. If your service doesn't have clinical guidelines that apply, discuss the situation with your medical director who can guide you through the process. Don't criticize another medical provider in your PCR or you risk becoming a star witness in a lawsuit against that provider; instead report problems within your service and discuss your concerns about other providers with your medical director.
Some states have "apology immunity"—statutes that permit medical providers to admit, and apologize for, errors in a manner that the apology cannot be held against them in litigation. But many states do not. It's important to consult with legal counsel before engaging in any discussions with a patient or their families where an error would be admitted. An apology is often what patients want, and juries will sometimes forgive a mistake if the provider has admitted it and done everything possible to insure that the mistake won't happen again.
References
1. O'Connor RE, Slovis CM, Hunt RC, et al. Eliminating errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care. 2002;6(1):107–113
2. Hobgood C, Bowen JB, Brice JH, et al. Do EMS personnel identify, report and disclose medical errors? Prehosp Emerg Care. 2006;10(1):21–27.
