Shortly after arriving at headquarters, you’re met by your new trainee Sarah. Sarah has just completed initial EMT training and has no field experience. You take a few minutes to make introductions and discuss the training expectations. Immediately after advising dispatch your unit is in service, you’re dispatched to a chest pain call.
Upon arriving on scene a crew of firefighters is tending to a 65-year-old female. The fire captain informs Sarah the patient has been suffering from chest pain for the past 30 minutes, has no known allergies and her vital signs are a heart rate of 72, respiratory rate of 20, blood pressure of 84/56 and SpO2 is 94% on room air. Sarah assumes patient care and, after administering aspirin, removes the nitroglycerin from the medication kit. Prior to administration, you remind her of the patient’s vital signs and she returns the nitroglycerin to the kit.
After delivering the patient to the ED, Sarah immediately says, “I can’t believe I did that, I knew her blood pressure was too low for nitroglycerin.” You recite the protocol for nitroglycerin administration, highlighting the dangers in the presentation of hypotension. You tell her mistakes like this are unacceptable and you expect the rest of the shift to be error free. Sarah says she understands and apologizes for the mistake.
Perfection is an unrealistic expectation and an unattainable goal. After all, emergency medical care is delivered by human beings, and humans are fallible. We must realize that mishaps will occur and not be fearful of them. Instead, we must learn from them and implement controls to prevent them from being repeated—or, at the very least, reduce the likelihood of a recurrence.
What should you have done in the above case? Should you simply say, “That was a close call, don’t worry about it, you’ll do better next time”? Maybe, depending on the behavior that led to the error.
According to David Marx’s Whack-a-Mole: The price we pay for expecting perfection, there are three zones of behavior that lead to mistakes: human error, at-risk behavior and reckless behavior. Human error is inadvertent or unintentional. At-risk behavior can be easily related to complacency or over-confidence (i.e., “I’ve been a medic for 20 years, I don’t need a check sheet”). Reckless behavior is when the risk outweighs the reward. Identifying that a treatment is contrary to protocol but providing it anyway would be considered reckless.
Answer the following questions to help you determine the behavior that led to the near-miss discussed earlier: Did the trainee fail to utilize a required medication cross-check procedure? Did they ignore input from other providers? Is there a flaw in the agency’s process? Did the trainee intend to administer the wrong medication? Did they simply make a mistake?
In this particular case, the agency hasn’t implemented a medication cross-check procedure and there was no input from other providers. Sarah tells you she knows the contraindications for nitroglycerin, but was nervous because it was her first call.
How should the FTO respond? First, they must identify the behavior and then respond appropriately. In this situation it appears that the actions of the trainee fall into Marx’s zone of human error.
Marx outlines the responses for each zone of behavior: Console the human error, coach the at-risk behavior and punish the reckless behavior. According to this model, we should console the trainee. This might sound something like, “We all make mistakes, don’t worry about it.” We must realize reprimanding or criticizing Sarah for this unintentional mistake may discourage her from reporting errors in the future, not to mention imposing an unrealistic expectation of perfection.
If, during the investigation, you identified at-risk behavior because they discounted the input of lower level providers, the trainee should be coached. Coaching in this scenario would be reminding the trainee of the importance of communication and highlighting the benefits of crew resource management.
If the behavior is discovered to be reckless, the trainee must receive corrective discipline. Reckless behavior is dangerous and must be dealt with swiftly. These sanctions should be in accordance with your agency’s discipline policy.
As an FTO, you must remember your trainees are imperfect and will inherently make mistakes. Your job is not only to discover the underlying behavior that led to the mistake, but more importantly to provide the appropriate corrective measure. This action can be as simple as providing reassurance and encouragement.