Administration and Leadership, Operations, Patient Care, Training

Learning From Near Misses: What the National Fire Fighter Near-Miss Reporting System means for EMS

Issue 5 and Volume 34.

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The National Fire Fighter Near-Miss Reporting System, which launched in August 2005, is actively collecting reports from EMS personnel related to incidents that put them in danger. What does this mean for you, the street-level provider or EMS administrator?„

Why Study Near Misses?
This report underscores the need to maintain vigilance and practice situational awareness. It_s not uncommon to respond to EMS calls involving an assault or a combative patient. In these situations, we always try to wait for local law enforcement to secure the scene. It_s the seemingly benign calls, such as the one in report #07-844 (above), where we can be easily fooled. When we_re dispatched to an “unresponsive patient,” “unknown medical,” or a “sick person” call, we may have no warning of potential hazards that await us. If we let our guard down on those “routine” calls, it sets us up for potentially dangerous consequences. Therefore, it_s important to maintain a certain degree of suspicion on all calls and always be prepared for the unexpected.

Can you imagine this scenario happening in your community? Have you experienced a similar incident? If so, did you keep it to yourself or tell your partner or co-workers? Did you file an official near-miss report? Remember, it_s never too late to submit a report.

The three goals of the Near-Miss Reporting System are to learn from real-life experiences, help formulate strategies to reduce the frequency of responder injuries and fatalities, and enhance the safety culture of fire and emergency services. In essence, by entering near misses into a national database, we_re able to extend the concept of a “kitchen table” discussion with our crew to thousands of peers around the country. The commercial airline industry, the military and those in clinical hospital settings have already benefited from analyzing these kinds of near-miss reports.

How Does the System Work?
Funded by the U.S. Department of Homeland Security_s Assistance to Firefighters Grant Program and managed by the International Association of Fire Chiefs, the reporting system is free, voluntary, confidential, non-punitive and secure, with the goal of improving emergency responder safety. The foundation of the system is a database of more than 2,200 reports, which continues to grow daily. Among the reports are cases when something went wrong that could have been avoided, as well as events when everything went well that serve as examples of how to successfully handle a dangerous incident.„

The database is accessible by any emergency responder, at any time. To submit a report, the first step is to enter your demographics, including department type and job/rank. Collecting this information helps preserve the reliability and relevance of the data. The second step is to enter the type of event, hours into your shift when it occurred and what you believe were the contributing factors. Third, you_ll enter the event description and lessons learned in your own words. For tips on this last part, visit the FAQ page on the site.„

The reports can be about something„that happened yesterday or 30 years ago. The incident can be one in which you were directly involved, one you witnessed or even one you heard about from someone else. The key is the educational component of the lessons learned.

Within 72 hours of submission, a reviewer will analyze your report and remove or generalize any names, departments, dates, times and other related information, in order to protect your identity. Reviewers are trained to identify any safety hazards requiring immediate action. Reviewers also code the reports into a database (once all identifiable information has been removed) in order to analyze trends. If contact information was provided and the reviewer needs additional information, you may be contacted. Information cannot be released to third parties because once the reports are coded they_re erased and cannot be tracked.„

Once the report is de-identified and reviewed, the report may be posted on the Web site for others to use as a learning tool. Your data may also be used in program reports, press releases or e-mail alerts.

Learning Opportunities
Besides submitting reports, you can also use the system to learn from others_ reports. One way to do this is to sign up for the free Report of the Week (ROTW). To sign up, click the link on the right-hand side of the homepage at„ or e-mail[email protected]and put “JEMS” in the subject line.„

You_ll receive a report each week that_s selected by the report reviewers to highlight a multitude of themes you can share with your crews. Some EMS themes have included combative patients, needlesticks and vehicle collision scenes. The weekly reports can be placed on bulletin boards, used for informal training sessions and incorporated into classroom curricula.

Another tool on the site is the “Search Report” feature. Reports can be searched by such categories as report number, incident type and region of the country. Perhaps the most useful way to access reports is through the keyword search. By typing in a keyword, you can access reports matching that keyword, enabling you to zero in on specific report categories.„

For example, if you were searching for reports involving a weapon, you would find 10 by using the keyword “weapon” and 40 using “gun.” For reports dealing with carbon monoxide exposures, you would find at least 37 reports by entering “CO,” eight by typing “carbon monoxide,” and six by entering “CO exposure.” Typing in “EMS” will yield about 150 reports. Try a few different words or combinations of words to increase the results returned by your keyword search.„

In addition to reading individual reports, there are many other valuable resources on the Web site. On the Resources page, you_ll find presentations, videos and photos, department policies, emergency vehicle driving programs, annual reports, training tools and a continually growing wealth of other information.„

The 2009 Near-Miss Calendar is one of the many useful tools on the Resources page. It can be downloaded and printed, or copies can be requested via the “Contact Us” link on the Web site. Each month of the calendar has a different theme, which includes reports, discussion ideas and other material related to the theme. For example, June addresses seatbelt usage, August highlights volatile EMS situations, and November deals with roadway safety.

Everyone Has a Story to Tell„
Submit a report and tell your story. Encourage your co-workers to do the same. The IAFC is challenging the entire EMS community to add to the increasing number of reports in the database in an effort to document our risks, learn from our experiences and help prevent future injury or fatality. Our safety is in our own hands.

Case StudyNear-Miss Report #07-844
Event Description:An ALS ambulance (EMT and paramedic), an ALS supervisor in a chase vehicle, and an ALS rescue (two paramedics for traffic control) were responding with lights and sirens for a male slumped over the wheel off to the right shoulder of the interstate, southbound. Local as well as state police units were en route non-emergency for this call. All units had to go northbound on the interstate to respond to the incident location southbound. When the ambulance was passing the location northbound, they noted and reported that a male was visible in the driver_s seat, slumped over the steering wheel. The cars reverse lights were on.„

As the supervisor was approaching the scene northbound, he noticed that the patient_s vehicle had begun to drift in reverse into traffic. The supervisor crossed the grass median and was able to push the car back off the roadway using the push bars on his suburban. The ambulance was at the scene southbound shortly afterwards. As the paramedic supervisor reached in to put the car into park, and shut off the ignition, the ambulance crew chocked the wheels of the patient_s car. Bystanders had stopped just south of the incident prior to EMS arrival and were approaching the scene at the time of the supervisor_s arrival to render assistance. They left when they saw that resources were at the scene.

The patient became alert while this was happening and was cooperative when the crew began to assess him to find out why he was slumped over the wheel. While we were assessing the patient, the paramedic supervisor did another walk around of the vehicle. As he approached from the A post area, he notice that the male patient had a 9 mm handgun lying on his lap, something that the crew did not notice at the time. The supervisor came around the driver_s side door, told the patient he was going to check his pulse and grabbed the gun to clear it from the patients reach. While the supervisor was removing the gun the patient stated, “You don_t have to do that” and began to reach for the gun. The supervisor was able to get the gun out of the car and lock it away in his vehicle. At that time we removed the male from the vehicle and patted him down for our safety. We removed a lock-blade knife and drug paraphernalia. While the EMT, also trained as a Tactical EMT, detained the patient, the paramedic continued his assessment. The male had no complaints other than being tired and stating that he had been up drinking and using cocaine overnight.

While we continued to assess the male, the supervisor switched over to the police frequency and asked them to expedite, advising them of the situation. The rescue had traffic controlled down to one lane furthest from the incident. Police arrived and took the patient into custody. While searching the vehicle, the police found two more handguns. The police also recovered a leather jacket with a badge on it and a portable police scanner which had the local police frequency as the primary frequency.

Lessons Learned:What we learned is that you should approach all “common calls” the same as we would a violent call. We must treat every call as an unsafe call until proven otherwise. We shouldn_t be paranoid, but we should be cautious.

Change the approach for slumped over the wheel calls. Approach the vehicle as the police do with one person at each side of the vehicle so you have a better view of what is going on in the car. This may also help with your patient assessment.

We currently don_t wear body armor for this type of call; we may change that in the near future.

The local police are re-evaluating their response guidelines to these calls as well.

Chocking the vehicle was smart, and it is something we commonly do on this type of call. It keeps you and the general public safe.

Quick Drill of EMS Near-Miss Reports
> Submit a report.
> Sign up for Report of the Week.
> Review the Resources page for useful tools for your organization.
> Download a free 2009 Near-Miss Calendar.
>„Request a Near-Miss trainer to make a presentation to your organization.
>„Utilize reports from<A href=””target=’_blank> in your training sessions.
> Be part of the solution, and prevent responder injuries and fatalities.„

A Cultural Study
The July 2008 issue ofAcademic Emergency Medicine included “Emergency medical services provider perceptions of the nature of adverse events and near misses in out-of-hospital care: An ethnographic view,” the results of a small study from the University of Rochester_s Department of Emergency Medicine. After conducting 15 in-depth interviews (73% ALS, 40% volunteer and 87% male), the researchers collected 61 events and found that 27 (44%) were near misses and 34 (56%) were adverse events. The provider discussed the event in only 21 cases, of which 10 (48%) were reported to a physician, and 9 (43%) to a supervisor; 4 (19%) were not reported, and none were reported to the patient. The researchers concluded that near misses and adverse„events were common among the studied„EMS providers but that the culture discouraged sharing of this information.

Captain Brad Van Ert, FF, EMT-P, has worked for the Downey (Calif.) Fire Department for 29 years. He began as a firefighter, then spent eight years as a FF/paramedic. He has served as a captain for nearly 20 years. He has a bachelor_s in occupational studies from California State University Long Beach and is currently working on his master_s in emergency services administration. Contact him at[email protected]