Airplanes, Streisand, and Patient Safety


I am sad that a paramedic was demoted for an error involving a spiked IV bag, but glad that this sparked an international discussion about the topic.  Unfortunately I have some experience with making mistakes, which earned me a spot on Mike Rubin’s EMS Voices column in July’s EMS World.

http://www.emsworld.com/print/EMS-World/EMS-Voices/1$17405

Twelve years ago the Institute of Medicine wrote about how to improve systems to prevent errors, which does not include beating people over the head when they make one.

http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

John Nance wrote an excellent book, Why Hospitals Should Fly: The Ultimate Flight to Patient Safety and Quality Care, which should be required reading for any EMS education program.   It is written as a novel from the perspective of an outsider visiting a hospital that has excelled at error prevention.  Not only are errors not punished, but reporting is encouraged.  There is continuous monitoring for near misses, and collaboration to improve systems.

http://www.amazon.com/Why-Hospitals-Should-Fly-Ultimate/dp/0974386065/ref=sr_1_1?s=books&ie=UTF8&qid=1317222254&sr=1-1

Which brings me to Barbara Streisand.  Shortly before the incident in Tennessee, Rogue Medic wrote about a patient who wished to have his care video taped.

http://roguemedic.com/2011/09/the-streisand-effect-and-ems-patient-care/

In the operating room of  Nance’s hospital, all surgeries are video taped.  Rules about what the tapes can be used for were designed by the surgical team. The tapes are used only for process improvement and never for punishment.   Safeguards are in place to prevent video from ever appearing on YouTube.  Should a malpractice case arise, the tapes are offered to the plaintiff before a subpoena.

So imagine what non-punitive, collaborative reviews of patient care in the back of an ambulance could do.  I would gladly narrate  a video of the cardiac arrest I got in trouble for to explain what I was thinking at each step, where we got off track, and how that error could be prevented in the future.  If this was widely practiced, how many other mistakes could be avoided?  How much better would our care be?

If this sounds intimidating at first, it should.  It would require our profession to grow up.  We would take responsibility for the care we give and the care given by the people we certify. From the patient’s perspective, would you rather be cared for by a service that tapes all patient contacts or one that chooses not to?

Here is some other excellent posts about errors in EMS:

http://tooldtowork.com/2011/09/scratching-my-head-2/

http://roguemedic.com/2011/09/what-is-the-right-response-to-a-treatment-error-part-i/

 

 

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