Study Examines Link Between Fatigue & Medical Errors

Fatigue & EMS Errors
Patterson PD, Weaver MD, Frank RC, et al. Association between poor sleep, fatigue and safety outcomes in emergency medical services providers. Prehosp Emerg Care. 2012;16(1):86—97.

Kudos again to Daniel Patterson, EMT, PhD, and his group for keeping EMS safety research in the spotlight. Readers may be familiar with the International Association of Fire Chief’s sleep deprivation project ( and the world health organization (WHO) listing of fatigue as a leading factor in medical error.

This study scientifically reconfirms the IAFC findings that EMS providers have poor sleep quality and fatigue. But Patterson goes a step further, showing an association between EMS worker fatigue and injuries, medical errors and safety-compromising behavior.

More than 547 EMS workers from 30 different EMS agencies completed three previously validated surveys. More than half of those surveyed had poor sleep quality or experienced severe fatigue while they were at work. The odds of injury and medical error were twice as high for those with poor sleep quality.

Commonly identified errors included protocol deviation, failure to secure a patient’s airway, dropping patients and medication errors. Threats to worker safety included high-speed ground or air transport, lifting patients and exposure to hazardous materials. Three-fourths of the respondents also reported being overweight or obese. Please don’t wait until an adverse event occurs on your crew to take action. Do it now: Take good care of yourself and get enough rest. The life you may save is your own.

Motorcycle Response
Van der Pols H, Mencl F, de Vos R, et al. The impact of an emergency motorcycle response vehicle on prehospital care in an urban area. Eur J Emerg Med. 2011;18(6):328—333.

This Dutch study sought to prove that EMS providers responding on motorcycles would decrease response times and improve survival from cardiac arrest in a densely populated urban area.

A total of 1,664 patients were evaluated, and the response times were decreased by 54 seconds. Unfortunately, the authors couldn’t show a decrease in mortality for resuscitations, but they discovered that the motorcycle was often dispatched for less acute cases and resulted in a non-transport (41% transport vs. 72% transport if an ambulance were dispatched first).

This study should make us wonder whether the specialty vehicles EMS uses to respond predisposes the clinician toward referrals and alternate care as opposed to a traditional “respond and transport” mode expected with an ambulance response.

Airway Advances
Two interesting studies from Japan that involve airway management during cardiac arrest are worthy of mention.

Nagao T, Kinoshita K, Sakurai A, et al. Effects of bag-mask vs. advanced airway ventilation for patients undergoing prolonged CPR in the prehospital setting. J Emerg Med. 2011. [Epub ahead of print].

This Tokyo group reviewed the charts of 355 cardiac arrest patients, comparing the survival to discharge rates for patients who received bag-valve-mask (BVM) ventilation vs. those who received an advanced airway–supraglottic (SG) airway or endotracheal intubation (ETI). They found no difference in survival, but they did note an increased return of spontaneous circulation (ROSC) and hospital admission in the advanced airway group.

This was a small observational and retrospective study. As is the case with many cardiac arrest studies, they contain many variables that aren’t taken into account. These included changes in the 2005 American Heart Association Guidelines for CPR and ECC protocols during the study, downtime before CPR, and the reason why the patient did or did not receive an advanced airway.

Kajino K, Iwami T, Kitamura T, et al. Comparison of supraglottic airway versus endotracheal intubation for the prehospital treatment of out-of-hospital cardiac arrest. Crit Care. 2011;15(5):R236. [Epub ahead of print].

This second Japanese airway study comes from Osaka and includes a review of 5,377 cardiac arrest cases for which advanced airways were used. The researchers’ goal was to compare survival to discharge for patients who received a supraglottic airway with those who received ETI.

Their conclusion was that there’s “no difference,” although they note that survival was associated with the timeliness of any advanced airway.

Using a multiple regression technique, the authors conclude that the shorter the time interval between collapse and placement of any of the advanced airways (SG or ET), the higher the likelihood of survival. They also notice that the presence of a person with ET training on scene, regardless of the airway used, was associated with improved survival. This reinforces that skilled clinicians with advanced skills are more successful regardless of the individual tools they use.

Ultimately, readers should conclude that both of these studies add little to our practice. There are simply too many variables and limitations in these studies for them to attribute survival to one variable, which would be airway management in this case.

Watch Box
Wampler DA, Christodoulides N, Floriano P, et al. Out-of-hospital fluid diagnostics in patients complaining of chest pain. Ann Emerg Med. 2011;10(Research Forum Abstracts_255):S262.

Twelve-lead ECGs for detection of ST-elevation myocardial infarctions (STEMIs) are now a prehospital standard of care for ALS units. But what about detecting the MI that has no ECG changes?

In this proof-of-concept project, paramedics in San Antonio, Texas, used oral swabs and blood samples on 63 patients to see whether they could detect non-STEMIs. This point-of-care diagnostic lab test checks the patient’s saliva for key biomarkers that may help diagnose both MIs and congestive heart failure. The results sound positive, so keep an eye out for more research in this area.

This article originally appeared in February 2012 JEMS as “Sleep Saves: Fatigue found as a leading cause of medical errors in the field.”

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