No More Blame & Shame

     As part of a routine skin biopsy procedure at his dermatologist's office, a healthy 22-year-old male receives an injection of lidocaine with epinephrine. Within minutes, his heart starts pounding and he begins to feel anxious. The dermatologist believes the patient is having an anaphylactic reaction and calls 9-1-1.

     When EMS arrives at the scene, the dermatologist informs them that the patient is suffering from an anaphylactic reaction. The patient reports that his heart is pounding, and he feels short of breath and very anxious. En route to the hospital, the paramedic asks his EMT partner to get the diphenhydramine and epinephrine vials out of the drug box. The paramedic later recalls asking the BLS partner to draw up "all of the diphenhydramine," but the EMT recalls hearing the paramedic ask for "all of the epinephrine." The paramedic takes the prepared syringe from the EMT and administers the medication intravenously, without checking the amount or the vial it was drawn from. Within minutes, the patient's rhythm changes to sustained ventricular tachycardia, and the patient complains of severe chest pain and diaphoresis, becomes distraught and says, "I think I'm dying." At this point, the paramedic realizes that he has just delivered 1 mg of 1:1,000 epinephrine via rapid intravenous bolus. Later, in the emergency department, it is determined that the patient suffered a myocardial infarction during the event. A lab analysis shows a rise in troponin levels, and a wall motion abnormality is found on echocardiogram, indicating that the patient sustained permanent damage to his heart muscle.

     Adverse events like this are not uncommon. In fact, more deaths occur each year due to medical errors than from motor vehicle crashes, breast cancer or AIDS. Although there are currently no reports that specifically look at EMS error rates, several suggest that EMS is no different than the rest of medicine with regard to patient safety. This is especially significant considering that 15,000 EMS systems and upwards of 800,000 EMS personnel respond to more than 16 million transport calls annually.

     The current EMS culture often uses "blame-and-shame" mentality. When an adverse event occurs, the common first response is to find out whose fault it is and discipline the individual. Unfortunately, this approach is not effective for improving overall patient safety, for several reasons. First, it ignores the fact that other factors in the system (besides the individual provider) might have contributed to, facilitated or even caused the adverse event to occur. This is important, because if these factors can be identified and modified, the chance of similar events occurring in the future can be reduced. Second, focusing blame on the individual doesn't prevent the same event from happening to another provider. Third, the blame-and-shame mentality creates a culture where EMS providers fear reprisal and may try to hide adverse events and near-misses rather than using them to improve the system. Unless management and system leaders are aware of events, they can't take steps toward reducing them.

     Other high-risk industries, such as aviation and nuclear power, have become highly reliable and safe because they have moved away from this mentality and instead use concepts like the systems approach to maximize their safety. The systems approach recognizes that all adverse events have multiple contributing factors, many of which are out of the provider's control. Aviation, for example, utilizes an Aviation Safety Reporting System (ASRS), which documents both adverse events and near-misses. Observing ASRS's success in aviation, members of the EMS community followed suit and developed a similar system: the Medical Error Prevention and Reporting System (MEPARS). A number of agencies around the country have implemented MEPARS or similar systems. Since its inception, MEPARS has not only identified several near-misses and adverse events, but has reduced the recurrence of similar events. The purpose of this article is to illustrate how using a systems approach in EMS, and using an event-reporting system like MEPARS, is a better method for reducing adverse events than the blame-and-shame approach.