‘Finding a Problem Is Like Finding a Diamond’


Improving Patient Safety and Reporting Systems

CarolinaFireJournal - James Winslow
James Winslow
04/16/2018 -

EMS agencies must focus on how they act as a system. Patient safety should be a central part of all EMS agencies. Looking at each EMS agency as part of a system of care is the only way to make this happen. Many EMS agencies have made the mistake of blaming individuals for patient care errors. Every system produces errors because of the way the system has been designed. When an error takes place, the system should not just blame the individual provider.

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The Japanese, who may be better at performance improvement than anyone else, say that finding a problem is like finding a diamond. The reason is that if they never know where the problems are then they can’t fix them. Agencies should have reporting systems or policies in place so that providers can report errors in a no fault environment where providers do not have to fear disciplinary measures.

The following is an example of how a possible error might be handled by a system administrator:

A patient has fallen and sustained a wrist fracture. The patient has no other injuries and the vital signs are stable. The paramedic wants to treat their pain so they administer four mg of morphine IV. The patient feels much better after medication administration. Afterwards the patient is uneventfully transported to the local emergency department. After leaving the hospital the paramedic realizes that they had accidentally given the patient midazolam instead of morphine. The paramedic immediately informs their supervisor.

There are two possible ways the system could handle the problem:

Option 1- Reprimand the paramedic and place a written warning in their file. Inform the paramedic that they must be more careful in the future and that they will be fired if this ever happens again.

Option 2- Thank the paramedic for reporting the problem and then ask the paramedic to describe how the error took place so that the system can determine what might have led to the error.

If the system went with option two the system might have learned that medications bags had recently been reorganized. The new organization put the Midazolam and Morphine next to each other. One of the medications had also recently been on shortage and the agency had to buy the medication from a new supplier. The new supplier packaged the medication differently which made the midazolam and morphine appear similar. As a result of the investigation the medication bags were changed to reduce the chance of the error happening again. In addition, the paramedic was thanked for immediately reporting the error which also increased the paramedic’s job satisfaction. If the system had gone with option 1 the system might not have learned about the cause for the error and would have alienated a hardworking paramedic.

In order to improve patient safety, agencies must make it easy for providers to report errors. If providers are scared to report errors then agencies will not know what to fix in their system. The Japanese, who may be better at performance improvement than anyone else, say that finding a problem is like finding a diamond. The reason is that if they never know where the problems are then they can’t fix them. Agencies should have reporting systems or policies in place so that providers can report errors in a no fault environment where providers do not have to fear disciplinary measures. If providers cannot safely report such issues then systems will have a difficult time improving patient safety.

Dr. Winslow graduated from Emergency Medicine residency from UNC-Chapel Hill in 2002 and completed his EMS Fellowship in 2003. He has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the NC Office of EMS in 2011. This document contains all protocol, procedures, and policies for all EMS agencies in North Carolina.
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Issue 32.4 | Summer 2018

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