Introduction of a Prehospital Critical Incident Monitoring System—Final Results

Abstract

Background:Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting.Hypothesis:A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting.Methods:This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations.Results:There were 454 incidents identified from 230 cases (mean = 2.0; 95% CI 1.8−2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI = 1.4−1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean = 2.0; 95% CI = 1.8−2.2 per case), and there were 74 incidents from 26 combined cases (mean = 2.9; 95% CI = 2.2−3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%).Conclusions:The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of “near miss” type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.

Deaths following prehospital safety incidents: an analysis of a national database

“…A completely reliable decision-making aid is yet to be devised, and so allocating limited resources to competing concerns remains challenging and vulnerable to human error. Adequate resourcing of ambulances services is another recurring theme in studies of prehospital safety 9 18 19. This is apparent in our study with shortages of vehicles or crew being the second most frequent cause of a delayed response.…”

“…This makes comparisons of the size of the problem of patient safety related to the volume of activity within ambulances services difficult. The most similar published study presents all prehospital incidents in an Australian rural ambulance service 19. In this study, although only 12 incidents causing death were included, these were much more common relative to both population size and volume of calls than in our study, occurring in around one in 10 000, compared with one in 176 500, responses.…”

“…Dispatch prioritisation features extensively in the emergency medicine literature18 19 and was the single largest cause of a delayed response in our study. While aids to dispatch decisions have been developed, at best they show only reasonable agreement with physician-allocated priorities 26.…”

“…A safety incident was identified as having occurred in one of every 250 ambulance responses, the majority of which resulted in no harm or only minor harm. Patient death followed only 2.6% of the incidents studied 19. A recent scoping review of safety in ambulance services in the UK concluded that safety is a significant issue for ambulance services but published studies on this topic are typically of poor quality with limited generalisability 20.…”

How safe is prehospital care? A systematic review

“…The studies used data from incident reporting systems or a record review (see Online Supplementary Material 2 for more information). All the incident reporting systems were for use by staff, with four anonymous reporting systems [ 37 , 41–43 ], and in two systems, the person submitting the report was identifiable [ 25 , 36 ].…”