Recommendations for Creating an EMS Culture of Safety

The following article is an EMS Insider exclusive from the May 2013 issue. EMS Insider, the premier publication for EMS managers, supervisors, chiefs and medical directors, is a must-have resource for the critical, accurate information EMS leaders need. The monthly publication offers quality investigative reporting, exclusive articles, management tips and the very latest news on legislative issues, grants, current trends and controversies. For more about how to become an Insider, click here.

Note: This is part one of a two-part article on strategies for creating an EMS culture of safety, based on the EMS Culture of Safety Project.

Designing safety measures for an inherently unsafe environment isn’t a new concept. Other industries, from aviation to transportation, have tackled the task. However, in the relatively young profession of EMS, implementing and enforcing safety measures has been a challenge. In part, the difficulty is attempting to change perceptions among EMS practitioners. Often, our view of ourselves as swashbuckling, yet resourceful (and charismatic) scallywags, doing whatever it takes to save lives, means that danger is a thrilling part of the job. “It’s a short distance from gods to pirates,” says Tom Judge, CCT-P, executive director of LifeFlight of Maine. Judge is a long time safety advocate and current member of the National Emergency Medical Services Advisory Council (NEMSAC).

For the past three years, 18 EMS leaders have been working on the National EMS Culture of Safety Project. The process involved collaboration and input from a variety of stakeholders both inside and outside the EMS community. A final draft was presented to NEMSAC at its December meeting. NEMSAC has provided feedback on the 97-page draft, which the committee will use to update the document. On May 15, they will submit the updated version to the National Highway Traffic Safety Administration (NHTSA), which will pass it through its internal clearance process. The final document is expected to be published in September.

Funding for the project was provided by NHTSA, with support from the Health Resources and Services Administration’s (HRSA) EMS for Children (EMSC) Program and the American College of Emergency Physicians (ACEP).

The primary objective, according to the EMS Culture of Safety chair Sabina Braithwaite, MD, MPH, FACEP, is to develop a strategy for a new EMS culture of safety within the profession that encompasses all aspects of EMS. “We don’t want something that sits on a shelf,” she says. It isn’t intended as a safety manual, addressing everyday operational details. Rather, it’s a high-level document that identifies six key elements meant to help move an EMS organization toward a culture of safety.

Judge praises the group for the thoroughness of their work. “If we fundamentally change the culture of safety–preventing harm to the public, the patient and better protecting our work force–then everyone has a role, even the person at the pointy end of the stick,” he says.

The EMS leaders involved in developing the strategy emphasize that serious changes to the practice of provider and patient safety won’t occur with the simple imposition of a new set of rules. “If we are going to reform the genetic code of what we do, there’s a whole element of culture that must change,” Judge says. “That change starts with a “˜trust culture,’ then a “˜reporting culture,’ a “˜learning culture,’ then this whole concept of “˜flexible culture.’ The final steps are “˜Just Culture’ and “˜generative culture.'” According to Judge, one of the most important insights he learned in the process is that a culture of safety is a loop, not a continuum.

The Culture of Safety group examined all aspects of provider and patient safety. They also considered the safety of the community by exploring ways to reduce ambulance crashes.

They encountered a number of difficulties, but none more significant than the lack of data on the extent of EMS-related injuries, illness, fatalities and adverse medical events. “Reporting requirements and mechanisms are inconsistent at best, making accurate research problematic,” they note in the report. A lack of standardization further complicates the assessment of available data.

Yet, it was the consensus of the EMS leaders involved in the project–plus the more than 20 stakeholder groups that contributed to the report, and the general EMS community that participated in the public comment process–that it would be unacceptable and irresponsible to withhold action until clear evidence could be assembled and assessed. Therefore, the recommendations of the EMS Culture of Safety project are based on science, best practices in other areas of healthcare, and trends both within and outside EMS.

A key issue in understanding the current state of the culture of safety, says Judge, is the low barrier to entry for EMS. It isn’t considered a profession, yet providers are responsible for conducting challenging tasks in a difficult environment under the umbrella of an ever-changing discipline. “In some ways, we do remarkably well,” Judge says. “It’s an incredibly complex endeavor, delivering mobile medicine, 24/7, in uncontrolled scenes under the worst of circumstances. The reality is that we’ve been more lucky than good.”

Judge acknowledges that not everyone will agree with the findings in the report, but he’s pragmatic. “This is going to be a journey,” Judge says. “If EMS is going to take this on, like any journey, there are going to be some people who don’t want to go.”

The reality is that the stakes are too high to fail. “The almost one million EMS professionals in the U.S.–and the hundreds of millions of citizens who expect and deserve functional, efficient, professional EMS to be there for every emergency and every disaster–are all depending on this endeavor to create a safer EMS system,” the report summary concludes.

Using Haddon’s matrix, the Culture of Safety project takes a unique approach to system safety. First, it examines the pre-event–what are the protective processes, design elements and strategies to improve safety prior to the 9-1-1 call? Next, what can be done during the actual response? Finally, how can we learn and improve systems safety design post event? The pre-event elements include education, safety standards, research and data.

EMS Education Initiatives
Education represents a significant opportunity in how the values and practical elements of a culture of safety are introduced and internalized. Whether initial programs or continuing education, safety must be fully integrated into each component of EMS education. “System safety principles need to be ingrained from the minute they walk through the door. Doing something safe is as important as doing something well,” Judge says.

The report writers warn not to expect quick acceptance. Cultural change, they state, will most likely be measured in generations.

Education initiatives include:

  • Incorporating leaders in safety education: The successful implementation of a safety culture hinges on buy-in from the top. Education efforts must include not just practitioners, but leaders, who will “own” EMS responder and patient safety. The report notes that EMS leaders are often promoted without much training in leadership skills or competencies. They recommend a more systematic approach that emphasizes safety and the concept of Just Culture.
  • Identifying at-risk candidates early: Entities that teach EMS education should actively identify candidates who display at-risk behavior or have risk-seeking attitudes.
  • Building clinical judgment: Changes in initial and ongoing education must move from a focus on technical skills to an emphasis on developing practitioners who are capable of critical thinking and judgment.
  • Transitioning new employees: The report recognizes that newly hired EMS employees are often paired with field providers who intentionally or unintentionally “undo” responder- and patient-safety education. Improvements to education programs that provide better real-world scenarios and increased preparation and support for field training officers or mentors are offered as possible solutions. The report notes that the National EMS Management Association recently created the EMS Field Training and Evaluation Program, which seeks to standardize and improve an organization’s approach to this often overlooked element of education.
  • Integrating safety into every component of EMS education: Safety must become an integral part of an organization’s culture. This includes everything from recruitment to continuing education.

EMS Safety Standards
The report recommends the establishment of an EMS Safety Resource Center (EMSSRC). The purpose is not to develop standards or duplicate work already being performed, but to act as a clearinghouse for existing work. The report notes that additional funding for research to develop and support standards is also needed.

The EMSSRC should, however, engage in a collaborative process to help prioritize the standards that need to be addressed and developed. Recommendations of safety topics, based on input from the EMS Culture of Safety Stakeholder Conference and public comments, included:

  • Physical fitness for practitioners;
  • Shifts/fatigue;
  • Violence categorization and reporting;
  • Ambulance design;
  • Safety competencies; and
  • Standards for safety-related information communicated to responders, to include anticipated data available through next-generation 9-1-1.

EMS Safety Data System
The current lack of data on the frequency and nature of EMS responder injuries, adverse medical events and other provider and patient safety issues stymies attempts to assess their impact on EMS and the cost to patients and society, as well as attempts to identify and measure corrective action. To rectify the situation, the report recommends the establishment of a National EMS Responder and Patient Safety Data System. This system would serve several purposes.

First, it would provide for a “national, robust, well-designed, secure data system encompassing key information about EMS safety.” The data would be available to researchers, policymakers and individual EMS provider agencies.

Second, it would serve to help establish a much-needed set of standard data elements and definitions, allowing for comparisons and aggregate datasets.

The National EMS Responder and Patient Safety Data System wouldn’t develop its own database. Rather, it would serve as link to existing data systems. It would be established with consideration to previous work, such as the 2007 NHTSA-sponsored report, Feasibility for an EMS Workforce Safety and Health Surveillance System; the Near-Miss Reporting System, developed and maintained by the International Association of Fire Chiefs; and NEMSIS, among others. Previously untapped sources of data could include insurance carriers and the Agency for Healthcare Research and Quality.

Two distinct aspects of patient safety must be addressed: protections from physical harm and prevention of medical errors. With regard to provider safety, surveillance of both mental and physical health conditions that may lead to negative outcomes should be tracked and analyzed.

Of course, privacy and liability concerns remain a potential obstacle. The report recommends engaging legal expert advice on relevant issues.

Judge concedes that recommendations such as those found in the EMS Culture of Safety report can be seen as regulations. The specter of regulations often frightens people.

However, he notes that it’s possible to implement safety standards without harming an industry. For example, he states that when we board a plane, we and our fellow passengers have an expectation that we’ll reach our destination safely. “Commercial aviation is the most regulated, open industry in the world. We don’t argue about regulation there,” he says.

The real fear is that the regulation will come from a place without domain expertise. “It’s always better to regulate ourselves,” he says.

It’s also helpful to remember what’s at stake. “We are still the only profession that gets to just walk into people’s lives and they trust that you are going to do the right thing,” Judge says. “We need to live up to those expectations.”

A copy of the draft report is available at

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