Administration and Leadership

NAEMSP 2017 Opening Keynote Discusses Error Prevention in Emergency Medicine

The opening Keynote presentation at the 2017 National Association of EMS Physicians Annual Meeting at the Hyatt Regency in New Orleans was presented by Terry Fairbanks, MD, a safety scientist and human factors engineer, pilot, former paramedic and EMS medical director.

His keynote address,What Safety Can EMS Learn from Aviation and Safety Engineering? was a unique comparison of two complex, high-risk industries, both of which have a history of strong hierarchical cultures delivering an inspiring perspective that challenged the way attendees think about safety.              

Dr. Fairbanks referenced an Institute of Medicine (IOM) report To Err is Human, published in November 1999, noting that in the 17 years after this report, while there are “pockets of change”, little has changed and more work needs to be done to reduce medical errors.

The two reasons Dr. Fairbanks cited to explain this lack of change:

  1. Preoccupation with medical error vs. a focus on reducing harm; and
  2. Ineffective solutions, specifically solutions we know aren’t scientifically sound.

As a human factors engineer, he noted that human error can’t be eliminated and frontline providers are often afraid to flag errors for risk of retribution.  Dr. Fairbanks recommends that we stop using the term, “error reporting,” because that causes fear among providers. In the words of a safety engineer: “We don’t redesign humans; We redesign the system in which we work”. 

Dr. Fairbanks cited three areas to address errors and correct them from reoccurring:

  1. Knowledge-based;
  2. Rule-based;
  3. Skill-based/automated routines.

As explained in the IOM report, human error can never be eliminated but it can be significantly reduced. Errors in actions, such as inadvertently shutting off a cardiac monitor/defibrillator instead of delivering a shock, can result in a time delay which can impact the provider’s ability to shock a patient early and result in a failed resuscitation. Continuous drilling can help avoid this type of predictable error.

A similar situation can be seen in the airline industry. Originally, the controls for the flaps (important on landing to produce “drag” to slow the aircraft) were located right next to the landing gear lever. This resulted in many pilots accidentally moving the wrong lever and crashing because they accidentally raised their landing gear.

Dr. Fairbanks also discussed the importance of device labeling, citing the horrible medical error that occurred when actor Dennis Quaid’s twins were accidentally given an overdose of heparin that was 100 times stronger than the dose that was ordered—the labels on each vial were nearly identical.

EMS providers used to inadvertently use a premixed lidocaine bag instead of a bag of normal saline when they were both packaged and labelled similarly and stored side by side in the EMS kits. Simple re-engineering medication separation eliminated most of these avoidable errors.

The true answer to error reduction, Dr. Fairbanks concluded, is adopting a true culture of safety in an organization where instead of punishing providers for errors we instead learn from them and implement processes to eliminate them by targeting one of the three methods of error prevention:

  1. Primary prevention: Error prevention via process design;
  2. Secondary prevention: Error prevention via hazard reporting; and
  3. Tertiary prevention: Error prevention via QA/QI analysis.

The third stage is what we traditionally do in EMS, and Dr. Fairbanks warns that this is a late stage and we should target our error prevention efforts closer to secondary prevention, which he feels is where we can make the most impact.