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Culture of Safety Varies Widely Among EMS Agencies


A study published in the October/December 2010 issue of Prehospital Emergency Care found that employees’ perception of "safety culture" varies widely among EMS agencies. The paper, titled "Variation in Emergency Medical Services Workplace Safety Culture," evaluated survey results from 61 EMS agencies in the U.S. and Canada.(1) Similar studies have looked at workplace safety culture in the hospital setting, but this is the first of its kind to look specifically at the prehospital work environment, said co-author Henry Wang, MD, MS, an associate professor of emergency medicine at The University of Alabama at Birmingham. Dr. Wang has spent much of his career studying prehospital airway management.

"In the process of trying to delve into the reasons for unwanted events in airway management, we started exploring dimensions of EMS culture," he said. "We discovered in some fairly focused group work that paramedics have a very unique and distinctive attitude toward their professional roles and their position within the healthcare environment. Some would characterize it as almost a macho attitude toward what they do: ‘I’m indestructible. I cannot possibly fail. I must be able to do all of the most current and advanced interventions; and it all must work together, because I save lives.' … We wondered out loud if those dimensions of their beliefs might impact the safety of their practices—not just in intubation, but in everything else."

The survey
The investigators developed an Emergency Medical Services Safety Attitudes Questionnaire by modifying the Intensive Care Unit Safety Attitudes Questionnaire, "a widely used and validated survey instrument characterizing workplace safety culture in hospital critical care units,” according to the paper. SAQs were initially developed to improve air travel by helping to identify the “breakdown in communications, fears of hierarchy and other cultural dimensions that no one was describing," Wang said. "The original crew resource management surveys identified all of those issues."

The EMS-SAQ includes 50 questions designed to measure "dimensions of workplace safety culture," including safety climate, teamwork climate, perceptions of management, job satisfaction, working conditions and stress recognition. (The entire SAQ is provided as an appendix to the paper, which is available online.) Respondents answered each question on a five-point scale, ranging from "strongly agree" to "strongly disagree." Individuals were eligible to participate if they work as a full-time, part-time or volunteer paramedic, EMT, first responder, prehospital nurse or EMS physician with at least one EMS shift per week.

In all, responses from 61 EMS agencies in the U.S. and Canada were evaluated. All types of agencies—hospital-based, fire, third-service/government and private/freestanding—are represented in the study, as are rural ground, urban ground, air, and services comprised of air and ground services.

The survey may one day help the EMS community understand how employees' perception of safety culture correlates to their agencies’ actual safety performance, but we’re not there yet.

"Nobody really knows how to measure safety records effectively at this point," said co-author Terry Fairbanks, MD, a former paramedic and EMS medical director who is now the director of the National Center for Human Factors Engineering in Healthcare, part of the MedStar Institute for Innovation in Washington, D.C. And self-reporting of adverse events continues to be a struggle, he said.

"There’s this feeling that you're bad or you’re weak if you make a mistake, and there's a general failure to recognize that sometimes the mistake is not the real cause—that it’s actually the environment or the system that set people up for an error."

Dr. Fairbanks contrasted the EMS community's attitude toward adverse events to the airline industry's, where team training and crew resource management is widely embraced. "When the FAA does a check-out ride of a commercial pilot team, if the pilot misses something and the other pilot catches it, it's not even recorded by the examiner. It's considered a team success. In healthcare in general but particularly in EMS, there's this cultural feeling that it’s not OK to make an error. That's really making it difficult for us to improve safety."

What they found
One of the most surprising findings was the wide variation in perceptions of safety culture among the participating agencies, said study co-author Daniel Patterson, PhD, MPH, EMT-B, an assistant professor at the University of Pittsburgh School of Medicine’s Department of Emergency Medicine and the director of research for the Center for Emergency Medicine of Western Pennsylvania Inc. For example, the percentage of positive responses to "safety climate" ran the gamut. At the low end of the spectrum, only about 15% of responding employees at one agency viewed their operations as safe. At the opposite end of the spectrum was an agency where nearly 100% of the participating employees viewed their operations as safe. "Driving from county to county, you're going to encounter a different culture of safety in different EMS catchment areas," Patterson said. "It's not surprising, but it’s a little eye opening."

The mean score for safety climate was greater for air-medical EMS agencies than the mean scores for private and fire-based agencies, the study reports.

"There are many reactions you can have to that," Fairbanks said. "If you take into account all the advancements that air aviation has made in the past decade or two, then it makes sense. The paramedics and nurses and EMTs may pick up on those checklist behaviors and all the other intricacies of being involved with aircrews. In my opinion, they're picking up on the behaviors of the pilots who automatically have more attention on safety than your typical ground service. But then again, this is just one study. If we replicated it many times, would we see the same thing? Probably, but we don’t know for sure."

Safety climate scores also tended to be higher among agencies with fewer employees, those with fewer annual patient contacts and those with a higher percentage of acute patients. "Potential factors underlying culture variation include regional practice differences, varying economic resources, and different leadership structure and styles," the authors reported.

Name, blame & shame
A major cultural shift in how EMS agencies view adverse events is necessary if the community is to achieve substantial improvements in safety, the authors said.
"We do not have a culture of transparency in EMS, and this is a stark contrast to the aviation industry and the nuclear power industry," Wang said. "I realized long ago that if you do not have a culture of transparency, you will not find mistakes and you will not be able to implement safe practices."

The majority of adverse events "are not due to recklessness, and they're not personal performance problems, but they’re actually system problems," Fairbanks said. "The goal is to develop a culture where everybody believes that, from the leadership on down to the EMT and paramedic on the street."

Safety can’t improve until the events that occur on the street are reported, and that won't happen if people are embarrassed or afraid to talk about errors. "We have this culture that many refer to as a 'name, blame and shame culture,' where when something goes wrong, we try to find out who's at fault, and we punish them," Fairbanks said. "We're missing the opportunity to know about these near misses, because people don't feel comfortable reporting them. That really starts with leadership, because we don't protect people.”
Instead of seeking out who to blame, a new EMT or paramedic should be encouraged to speak up if they believe their veteran partner is about to make a mistake. The veteran should be receptive to their input and respond positively, even if their less-experienced partner is wrong. "I think anybody reading this article will acknowledge that doesn't happen anywhere in EMS right now," Fairbanks said. In addition, he said any useful adverse event reporting system will be "anonymous, protective and easy to use."

A useful tool
The EMS-SAQ used to conduct this study is still in use and available to EMS agencies at no cost (see the end of this article for more information). Until now, quantifying exactly what makes an agency superior has been subjective. "What's a good EMS agency? Ask 10 medical directors and they can rattle off 10 good ones. Ask them which are the bad ones, and they’ll rattle off 10 more," Wang said. "But nobody really knows what that means. It's all based on hearsay and individual perceptions, but not the perception of the whole team systematically studied in this manner."

The authors hope EMS agencies will embrace the EMS-SAQ as a unique benchmarking opportunity. "This provides EMS managers with a reliable and valid tool to assess and compare themselves in terms of safety culture," Fairbanks said. "This is a crucial first step, because once we begin measuring the culture effectively, then we can start to measure interventions and see what helps improve the culture."

There's much work to be done. "We've heard about safety issues, the culture of safety, errors, adverse events, mistakes, etcetera, from other sectors of healthcare for nearly a decade. EMS is behind the curve, and this is a wakeup call," Patterson said. "We need to look deeper into the safe and unsafe practices of ground and air medical services. Now we have a tool to do that."

Study Co-Author Daniel Patterson invites EMS agencies to participate in free safety culture benchmarking. In exchange for participating in research, the University of Pittsburgh’s EMS Agency Research Network (EMSARN) will provide EMS agencies with a detailed safety report. For more information, visit www.EMSARN.org and www.emssafetyculture.org.

1. Prehospital Emergency Care. 2010;14:448-460.


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