Objective-To identify Emergency Medical Services (EMS) provider perceptions of factors that may affect the occurrence, identification, reporting, and reduction of near misses and adverse events in the pediatric EMS patient.Methods-This was a subgroup analysis of a qualitative study examining the nature of near misses and adverse events in EMS as it relates to pediatric prehospital care. Complimentary qualitative methods of focus groups, interviews, and anonymous event reporting were used to collect results and emerging themes were identified and assigned to specific analytic domains.Results-Eleven anonymous event reports, 17 semi-structured interviews, and 2 focus groups identified 61 total events, of which 12 (20%) were child-related. Eight (66%) of those were characterized by participants as having resulted in no injury, 2 (16%) resulted in potential injury, and 2 (16%) involved an ultimate fatality. Three analytic domains were identified which included the following five themes: reporting is uncommon, blaming errors on others, provider stress/discomfort, errors of omission, and limited training. Among perceived causes of events, participants noted factors relating to management problems specific to pediatrics, problems with procedural skill performance, medication problems/calculation errors, improper equipment size, parental interference, and omission of treatment related to providers' discomfort with the patient's age. Few participants spoke about errors they had themselves committed; most discussions centered on errors participants observed being made by others.Conclusions-It appears that adverse events and near misses in the pediatric EMS environment may go unreported in a large proportion of cases. Participants attributed the occurrence of errors to the stress and anxiety produced by a lack of familiarity with pediatric patients and to a reluctance to cause pain or potential harm, as well as to inadequate practical training and experience in caring for the pediatric population. Errors of omission, rather than those of commission, were perceived to predominate. This study provides a foundation on which to base additional studies of both qualitative * Note: Dr. O'Gara is now with Rochester General Hospital, Rochester, NY, and Dr. Pennington is now with Boston University/Boston Medical Center Department of Surgery, Boston, MA. and quantitative nature that will shed further light on the factors contributing to the occurrence, reporting, and mitigation of adverse events and near misses in the pediatric EMS setting.

Objectives: The objectives were to examine the perceptions of emergency medical services (EMS) providers regarding near-misses and adverse events in out-of-hospital care.Methods: This study uses qualitative methods (focus groups, interviews, event reporting) to examine the perceptions of EMS providers regarding near-misses and adverse events in out-of-hospital care. Results were reviewed by five researchers; analytic domains were assigned and emerging themes were identified. Descriptive statistics were calculated.Results: Fifteen in-depth interviews (73% advanced life support [ALS], 40% volunteer, and 87% male) resulted in 50 event descriptions. Eleven additional event reports were obtained from the anonymous reporting system. Of the 61 total events, 27 (44%) were near-misses and 34 (56%) were adverse events. Fourteen (23%) involved a child (<19 years). Types of error included 33 clinical judgment (54%), 13 skill performance (21%), 9 medication event (15%), 3 destination choice (5%), and 3 others (5%). For the 21 cases where the provider discussed the event, 10 (48%) were reported to a physician, and 9 (43%) to a supervisor; 4 (19%) were not reported, and none were reported to the patient. Focus groups supported interview and event report data. Emerging themes included a focus on the errors of others and a ''blame-and-shame'' culture.Conclusions: Adverse events and near-misses were common among the EMS providers who participated in this study, but the culture discourages sharing of this information. Participants attributed many events to systems issues and to inadequacies of other provider groups. Further study is necessary to investigate whether these hypothesis-generating themes are generalizable to the EMS community as a whole.ACADEMIC EMERGENCY MEDICINE 2008; 15:633-640 ª

Summary:Our goal was to compare direct and indirect medical costs and quality of life associated with inpatient vs outpatient autologous hematopoietic stem cell transplantation (AuHSCT). Twenty-one sequential outpatients and 26 inpatients were enrolled on this prospective trial. All candidates for AuHSCT were screened for eligibility for outpatient transplantation. Patients with either breast cancer or hematologic malignancy, insurance coverage for the outpatient procedure, one to three caregivers available to provide 24 h coverage, and no significant comorbidities were eligible to participate. Patients without caregivers or insurance coverage for outpatient transplant were accrued to the study in a consecutive manner as inpatient controls, based on willingness to participate in the quality of life portion of the study and to permit review of their hospital and billing records. Approximately half of all 139 prospective outpatient candidates were ineligible because they lacked a caregiver. Most commonly, the patient without a caregiver was single or widowed or their family and friends were needed to provide childcare. Most caregivers were college educated from families with incomes greater than $80 000. Indirect costs to the caregivers totaled a median of $2520 (range $684-$4508), with the majority attributed to lost 'opportunity costs'. Overall, there were significant differences in the total costs of treatment for inpatient vs outpatient AuHSCT ($40 985 vs $29 210, P Ͻ 0.01)). In general, no significant differences were detected between inpatient and outpatient scores on quality of life measures. Although significant cost savings were associated with outpatient transplantation, this approach was applicable to only half of our otherwise eligible candidates because of a lack of caregivers. The financial burden associated with the caretaking role may underlie this finding.

Emergency medical services providers are quite reluctant to perform MMR, and this is likely related to their perception of a high risk of contagion. The availability of barrier devices greatly decreases this reluctance, but EMS personnel carry such devices infrequently.