In exposure avoidance, we choose not to engage in a particular activity. For instance, a system may choose not to have specially trained EMS providers for tactical response. This may reduce the likelihood of exposure to particular risks (e.g., gunfire, exposure to violent criminals), but it may also cause problems within a community relying on that service. In many cases, you may not be able to avoid the exposure; therefore, you must attempt to control the risk through other strategies.
Segregation of loss exposures involves structuring your activities and resources in such a way so that if an incident occurs, it does not affect the entire organization. An example would be using multiple vendors for medication supplies or fleet services. It could also include storing supplies at individual posts in addition to a centralized warehouse.
Risk transfer essentially entails getting someone else to do it for you. You may look, for example, at having another agency function as your PSAP, and thus assume the liability for call screening. You may also transfer the financial liability for an activity you wish to retain through the purchase of insurance from a third party.
Another option is risk retention, which is deciding how much risk you want to assume. Will you go self-insured and be responsible for first dollar on all losses, but still purchase insurance for excess coverage? Many agencies are becoming self-insured for auto accidents and worker's compensation.
After an Event
Once an event has occurred, there are things that need to be done immediately to lessen the impact on the organization and prevent future occurrences.
First, initiate an investigation. Take statements from involved employees and obtain copies of call reports, incident reports, police reports and all recordings (e.g., dispatch tapes from involved agencies, medical control recordings), photographs and video. Gather copies of current SOPs, memos and policies that pertain to the incident. Get quality assurance records, but check with your legal counsel as to how to maintain confidentiality, particularly if you anticipate being named in a lawsuit. Keep these files in a secure area. The purpose of the internal investigation is to identify what part of the process failed and propose new methods for prevention.
As an example, say a crew drops a patient while unloading them from the ambulance. The crew should notify the supervisor; secure an RMA (assuming the patient does not complain of additional injury); notify the receiving facility of the event; and document the name of the person accepting the report. The stretcher should be taken out of service and evaluated by a qualified technician. A manager should follow up with patient to ensure there are no additional complaints.
While many systems do not have the resources for a full-time risk manager, this should not limit the implementation of risk reduction techniques. Risk management principles can and should be practiced by every member of the organization.
Other resources include your insurance company--it has an interest in helping your agency reduce its losses. It will also have volumes of historical and comparative data. You can also benchmark yourself against the Bureau of Labor Statistics database, which is available at www.bls.gov/data. Another readily available resource is the National Fire Protection Association. The NFPA has developed standards for establishing a risk management plan. Two documents worth obtaining are NFPA 1500: Standard on Fire Department Occupational Safety and Health Program and NFPA 1521: Standard for Fire Department Safety Officer.
The American Society for Healthcare Risk Management offers a certification program that covers the entire spectrum of risk management in the healthcare setting. Lastly, do not forget the Occupational Safety & Health Administration. OSHA offers a tremendous amount of resources, including downloadable training programs, e-tools and templates.
Peter I. Dworsky, MPH, EMT-P, CCEMT-P, is the director of special operations and safety and risk management for MONOC Mobile Health Services in New Jersey, where he is responsible for injury-prevention programs, disaster preparedness and emergency management, and grant writing. He has been involved in many aspects of EMS and emergency management since 1985. For more information, e-mail Peter.Dworsky@MONOC.ORG.