Administration and Leadership, Columns

Identifying and Learning from Clinical Errors in Prehospital Care

Issue 5 and Volume 42.

“To err is human, to forgive divine.” This quote from Alexander Pope’s An Essay on Criticism formed the title of the 1999 Institute of Medicine report on the impact of medical errors in the United States. Although we knew medical errors occurred, prior to this report we had never quantified its impact on healthcare and our citizens. This report, published 17 years ago, estimated a 4% rate of medical errors for hospitalized patients. Subsequent research has shown this 4% error rate to be consistent with patients in the ED.

Although we don’t have definitive data on error rates in EMS, given the consistency of rates of errors in hospitalized patients and ED patients, it wouldn’t be illogical to presume a rate of 4% in the prehospital environment.

It may even be reasonable to speculate that the rate could be even higher given the complexity of our patients, austere conditions and differences in provider education.

Consider a hypothetical EMS service that has 100,000 patient encounters per year. Based on the 4% error rate, the agency could expect to have 4,000 adverse patient events per year.

If we then presume that the rates of death from these errors of 6-12% in the hospital/ED setting are also consistent in the EMS, that equates to 240-480 deaths per year.

If we continue the comparison to rates in the hospital, around 1/3 of those deaths from errors are preventable, or 80-160 in this hypothetical EMS system. The concerns aren’t isolated to large urban environments; even with a system caring for 10,000 patients each year, these calculations would mean one adverse event every day and 2-4 deaths per month.

A Critical Problem

Although the general public is concerned about police shootings and fire-related deaths, the number of these that occur each day are likely much smaller than the high number of deaths due to medical errors.

Why isn’t there outrage that we’ve done little in EMS to effect change, despite the fact that we’ve known about this critical problem for almost two decades?

The answer is complex, but one of the reasons is that patients, and perhaps providers themselves, may not realize that an error occurred. Although the EMS industry spends billions of dollars each year on ambulances, wheels and medical equipment, we spend relatively little on assessing the quality of the work we do and the errors associated.

A likely contributor to the lack of public pressure for EMS quality improvement is that citizens and elected officials alike have a “butts in seats” mentality with regard to public safety agencies. It’s much easier to conceptualize and monitor public safety services in terms of numbers of providers, numbers of apparatus on the streets, and response times than quality of care and the impact of errors.

These are also much more challenging issues to solve-if response times increase, you simply add more units or redistribute resources, but how do you effectively detect and then impact system-wide deficiencies in clinical decision-making?

Striving for Perfection

The fix isn’t easy, but part of the solution to addressing the medical error crisis in EMS is first to admit that there’s a problem. EMS agencies must understand that hiding errors by either not making an effort to discover them or by not appropriately mitigating them is unethical.

We can’t settle on “doing the best we can” in regards to quality because although EMS administrators may be comforted by this philosophy, our patients and our providers suffer. Providers suffer because we have a workforce that strives for excellence and when they encounter clinical challenges that result in error, they need to be afforded the opportunity to learn from the error, improve their clinical practice and then share it with others.

Error-based improvement is how medical students, interns, residents, and attending physicians learn how to better practice medicine (e.g., morbidity and mortality sessions) and is often a critical piece missing from our EMS systems.

EMS, like the rest of medicine, is a highly complex operation with countless interdependencies related to personnel, equipment, patient factors and many others. It’s impossible to completely prevent errors, but that shouldn’t deter us from trying.

EMS systems must choose to prioritize patient safety by directing resources to detecting and identifying when we make mistakes and developing monitoring systems, clinical oversight and performance improvement programs to mitigate these clinical errors.

It’s a disservice to our patients when we make clinical errors but the impact is worsened when we don’t learn from our mistakes.