Patient safety in emergency medical services: A systematic review of the literature

Prehospital Emergency Care

Volumn 16, Issue 1, 2012, Pages 20-35

  Bigham, Blair L ^a   Buick, Jason E ^a,b   Brooks, Steven C ^a,b,c   Morrison, Merideth ^d   Shojania, Kaveh G ^b,d,e   Morrison, Laurie J ^a,b  

^a ST MICHAEL'S HOSPITAL   (Canada)

^b UNIVERSITY OF TORONTO   (Canada)

^c SUNNYBROOK RESEARCH INSTITUTE   (Canada)

^d County of Simcoe Paramedic Services ^*  (Canada)

^e UNIVERSITY OF TORONTO   (Canada)

Author keywords

adverse event; ambulance; emergency medical services; medication error; patient safety; prehospital; systematic review

Indexed keywords

AMBULANCE; DRUG TOXICITY; EMERGENCY HEALTH SERVICE; HUMAN; MEDICAL ERROR; METHODOLOGY; ORGANIZATION AND MANAGEMENT; PATIENT CARE; REVIEW; RISK ASSESSMENT; SAFETY;

AMBULANCES; DRUG TOXICITY; EMERGENCY MEDICAL SERVICES; HUMANS; MEDICAL ERRORS; PATIENT-CENTERED CARE; RISK ASSESSMENT; SAFETY;

EID: 82555194434     PISSN: 10903127     EISSN: 15450066     Source Type: Journal    
DOI: 10.3109/10903127.2011.621045     Document Type: Review

References (109)

1. Bigham BL, Maher J, Brooks SC, et al. Patient Safety in Emergency Medical Services: Advancing and Aligning the Culture of Patient Safety in EMS. Edmonton, Canada: Canadian Patient Safety Institute, 2010.
2. Runciman W, Hibbert P, Thomson R, Van der Schaaf T, Sherman H, Lewalle P. Towards an international classification for patient safety: key concepts and terms. Int J Qual Health Care. 2009;21:18-26.
3. Altman DE, Clancy C, Blendon RJ. Improving patient safety-five years after the IOM report. N Engl J Med. 2004;351:2041-3. (Pubitemid 39482495)
4. Brickell TA, Nicholls TL, Procyshyn RM, et al. Patient Safety in Mental Health. Edmonton, Canada: Canadian Patient Safety Institute and Ontario Hospital Association, 2009.
5. Rust TB, Wagner LM, Hoffman C, Rowe M, Neumann I. Broadening the patient safety agenda to include safety in longterm care. Healthc Q. 2008;11 (3 Spec No.): 31-4.
6. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, 1999.
7. Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30:581-9.
8. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff (Millwood). 2011;30:596-603.
9. Mulrow C, Oxman A. Cochrane Collaboration Handbook [Cochrane review on CD-ROM]. Oxford, England: Cochrane Library, Update Software, 1997.
10. Canadian Patient Safety Institute. Advisory Group. Available at: http://signup. patientsafetyinstitute.ca/English/Initiatives/ EmergencyMedicalServices/Pages/default.aspx. Accessed April 27, 2011.
11. Mason S, Knowles E, Freeman J, Snooks H. Safety of paramedics with extended skills. Acad Emerg Med. 2008;15:607-12.
12. Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care. 2008;12:486-94.
13. U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Patient Safety Network. Available at: http://www.PSNet. ahrq.gov/. Accessed April 18, 2011.
14. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362:1698-707.
15. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-9.
16. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32. (Pubitemid 46021509)
17. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693-700.
18. Atack L, Maher J. Emergency medical and health providers' perceptions of key issues in prehospital patient safety. Prehosp Emerg Care. 2010;14:95-102.
19. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-80. (Pubitemid 36993075)
20. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488-96. (Pubitemid 46780952)
21. Bigham BL, Bull E, Morrison M, et al. Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit. Can J Emerg Med. 2011;13:13-8.
22. World Health Organization. International Classification for Patient Safety. Available at: http://www.who.int/entity/patientsafety/implementation/ taxonomy/en/index.html. Accessed December 2, 2009.
23. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care. 2001;5:261-9. (Pubitemid 32612401)
24. Saunders CE, Heye CJ. Ambulance collisions in an urban environment. Prehosp Disaster Med. 1994;9:118-24.
25. Studnek JR, Crawford J. Factors associated with back problems among emergency medical technicians. Am J Ind Med. 2007;50:464-9. (Pubitemid 46883939)
26. Batchelder AJ, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N. Simulation as a tool to improve the safety of pre-hospital anaesthesia-a pilot study. Anaesthesia. 2009;64:978-83.
27. Brown LH, Hubble MW, Cone DC, et al. Paramedic determinations of medical necessity: a meta-analysis. Prehosp Emerg Care. 2009;13:516-27.
28. Clesham K, Mason S, Gray J, Walters S, Cooke V. Can emergency medical service staff predict the disposition of patients they are transporting? Emerg Med J. 2008;25:691-4.
29. Cone DC, Wydro GC. Can basic life support personnel safely determine that advanced life support is not needed? Prehosp Emerg Care. 2001;5:360-5. (Pubitemid 32964224)
30. Dale J, Williams S, Foster T, et al. Safety of telephone consultation for "non-serious" emergency ambulance service patients. Qual Saf Health Care. 2004;13:363-73. (Pubitemid 39389398)
31. Gray JT, Wardrope J. Introduction of non-transport guidelines into an ambulance service: a retrospective review. Emerg Med J. 2007;24:727-9. (Pubitemid 47520887)
32. Haines CJ, Lutes RE, Blaser M, Christopher NC. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care. 2006;10:213-9.
33. Hauswald M. Can paramedics safely decide which patients do not need ambulance transport or emergency department care? Prehosp Emerg Care. 2002;6:383-6.
34. Knapp BJ, Tsuchitani SN, Sheele JM, Prince J, Powers J. Prospective evaluation of an emergency medical services-administered alternative transport protocol. Prehosp Emerg Care. 2009;13:432-6.
35. McDermott FT, Cooper GJ, Hogan PL, Cordner SM, Tremayne AB. Evaluation of the prehospital management of road traffic fatalities in Victoria, Australia. Prehosp Disaster Med. 2005;20:219-27.
36. Pringle RP Jr, Carden DL, Xiao F, Graham DD Jr. Outcomes of patients not transported after calling 911. J Emerg Med. 2005;28:449-54. (Pubitemid 40523695)
37. Chan EW, Taylor SE, Marriott J, Barger B. An intervention to encourage ambulance paramedics to bring patients' own medications to the ED: impact on medications brought in and prescribing errors. Emerg Med Australas. 2010;22:151-8.
38. Cushman JT, Fairbanks RJ, O'Gara KG, et al. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care. 2010;14:477-84.
39. Dewhurst AT, Farrar D, Walker C, Mason P, Beven P, Goldstone JC. Medical repatriation via fixed-wing air ambulance: a review of patient characteristics and adverse events. Anaesthesia. 2001;56:882-7. (Pubitemid 32821274)
40. Eastwood KJ, Boyle MJ, Williams B. Paramedics' ability to perform drug calculations. West J Emerg Med. 2009;10:240-3.
41. Fairbanks RJ, Crittenden CN, O'Gara KG, et al. Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. Acad Emerg Med. 2008;15:633-40.
42. Frakes MA, High K, Stocking J. Transport nurse safety practices, perceptions, and experiences: the air and surface transport nurses association survey. Air Med J. 2009;28:250-5.
43. Hobgood C, Bowen JB, Brice JH, Overby B, Tamayo-Sarver JH. Do EMS personnel identify, report, and disclose medical errors? Prehosp Emerg Care. 2006;10:21-7. (Pubitemid 43154899)
44. Hobgood C, Weiner B, Tamayo-Sarver JH. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? Acad Emerg Med. 2006;13:443-51.
45. Hobgood C, Xie J, Weiner B, Hooker J. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types. Acad Emerg Med. 2004;11:196-9. (Pubitemid 38166975)
46. Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics. Prehosp Emerg Care. 2000;4:253-60. (Pubitemid 30447919)
47. Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118:1493-500. (Pubitemid 46393795)
48. LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T. Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care. 2005;9:439-44. (Pubitemid 43154619)
49. MacDonald RD, Banks BA, Morrison M. Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15:923-31.
50. Patterson PD, Huang DT, Fairbanks RJ, Simeone S, Weaver M, Wang HE. Variation in emergency medical services workplace safety culture. Prehosp Emerg Care. 2010;14:448-60.
51. Ricard-Hibon A, Chollet C, Belpomme V, Duchateau FX, Marty J. Epidemiology of adverse effects of prehospital sedation analgesia. Am J Emerg Med. 2003;21:461-6. (Pubitemid 37322882)
52. Seymour CW, Kahn JM, Schwab CW, Fuchs BD. Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care. 2008;12(3):R71.
53. Shaw R, Drever F, Hughes H, Osborn S, Williams S. Adverse events and near miss reporting in the NHS. Qual Saf Health Care. 2005;14:279-83. (Pubitemid 41133183)
54. Stella J, Davis A, Jennings P, Bartley B. Introduction of a prehospital critical incident monitoring system-pilot project results. Prehosp Disaster Med. 2008;23:154-60.
55. Vilke GM, Tornabene SV, Stepanski B, et al. Paramedic self-reported medication errors. Prehosp Emerg Care. 2007;11:80-4. (Pubitemid 46005648)
56. Wang HE, Fairbanks RJ, Shah MN, Abo BN, Yealy DM. Tort claims and adverse events in emergency medical services. Ann Emerg Med. 2008;52:256-62.
57. Wang HE, Weaver MD, Abo BN, Kaliappan R, Fairbanks RJ. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18:213-6.
58. Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Clinical handover of patients arriving by ambulance to the emergency department-a literature review. Int Emerg Nurs. 2010;18:210-20.
59. Carter AJ, Davis KA, Evans LV, Cone DC. Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care. 2009;13:280-5.
60. Evans SM, Murray A, Patrick I, et al. Assessing clinical handover between paramedics and the trauma team. Injury. 2010;41:460-4.
61. Owen C, Hemmings L, Brown T. Lost in translation: maximizing handover effectiveness between paramedics and receiving staff in the emergency department. Emerg Med Australas. 2009;21:102-7.
62. Vilensky D, MacDonald RD. Communication errors in dispatch of air medical transport. Prehosp Emerg Care. 2011;15:39-43.
63. Zimmer M, Wassmer R, Latasch L, et al. Initiation of risk management: incidence of failures in simulated emergency medical service scenarios. Resuscitation. 2010;81:882-6.
64. Becker LR, Zaloshnja E, Levick N, Li G, Miller TR. Relative risk of injury and death in ambulances and other emergency vehicles. Accid Anal Prev. 2003;35:941-8.
65. Bull MJ, Weber K, Talty J, Manary M. Crash protection for children in ambulances. Annu Proc Assoc Adv Automot Med. 2001;45:353-67.
66. De Graeve K, Deroo KF, Calle PA, Vanhaute OA, Buylaert WA. How to modify the risk-taking behaviour of emergency medical services drivers? Eur J Emerg Med. 2003;10:111-6.
67. Johnson TD, Lindholm D, Dowd MD. Child and provider restraints in ambulances: knowledge, opinions, and behaviors of emergency medical services providers. Acad Emerg Med. 2006;13:886-92. (Pubitemid 44094139)
68. King BR, Woodward GA. Pediatric critical care transport-the safety of the journey: a five-year review of vehicular collisions involving pediatric and neonatal transport teams. Prehosp Emerg Care. 2002;6:449-54.
69. Levick NR, Swanson J. An optimal solution for enhancing ambulance safety: implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annu Proc Assoc Adv Automot Med. 2005;49:35-50. (Pubitemid 43226951)
70. Ray AF, Kupas DF. Comparison of crashes involving ambulances with those of similar-sized vehicles. Prehosp Emerg Care. 2005;9:412-5. (Pubitemid 43154615)
71. Ray AM, Kupas DF. Comparison of rural and urban ambulance crashes in Pennsylvania. Prehosp Emerg Care. 2007;11:416-20. (Pubitemid 47509261)
72. Bledsoe BE, Smith MG. Medical helicopter accidents in the United States: a 10-year review. J Trauma. 2004;56:1325-8; discussion 1328-9. (Pubitemid 38901848)
73. De Lorenzo RA, Freid RL, Villarin AR. Army aeromedical crash rates. Mil Med. 1999;164:116-8. (Pubitemid 29096046)
74. Dery M, Hustuit J, Boschert G, Wish J. Results and recommendations from the helicopter EMS pilot safety survey 2005. Air Med J. 2007;26:38-44. (Pubitemid 46043076)
75. Frakes MA, Kelly JG. A survey of adherence to communitygenerated safety guidelines in rotor-wing air medical programs. Air Med J. 2007;26:100-3. (Pubitemid 46336579)
76. Thies KC, Sep. D, Derksen R. How safe are HEMS-programmes in Germany? A retrospective analysis. Resuscitation. 2006;68:359-63. (Pubitemid 43288088)
77. Thomas F, Romig L, Durand J, Hutton K, Handrahan D. Critical issues facing the air medical transport community. The 2003 Air Medical Leadership Congress survey. Air Med J. 2005;24:106-11.
78. Belway D, Henderson W, Keenan SP, Levy AR, Dodek PM. Do specialist transport personnel improve hospital outcome in critically ill patients transferred to higher centers? A systematic review. J Crit Care. 2006;21:8-17; discussion 17-8.
79. Deasy C., O'Sullivan I. Transfer of patients-from the spoke to the hub. Ir Med J. 2007;100:538-9.
80. Duke GJ, Green JV. Outcome of critically ill patients undergoing interhospital transfer. Med J Aust. 2001;174:122-5. (Pubitemid 32149356)
81. Fan E, MacDonald RD, Adhikari NK, et al. Outcomes of interfacility critical care adult patient transport: a systematic review. Crit Care. 2006;10(1):R6.
82. Flabouris A, Runciman WB, Levings B. Incidents during outof-hospital patient transportation. Anaesth Intensive Care. 2006;34:228-36.
83. Fried MJ, Bruce J, Colquhoun R, Smith G. Inter-hospital transfers of acutely ill adults in Scotland. Anaesthesia. 2010;65:136-44.
84. Gebremichael M, Borg U, Habashi NM, et al. Interhospital transport of the extremely ill patient: the mobile intensive care unit. Crit Care Med. 2000;28:79-85. (Pubitemid 30091033)
85. Hatherill M, Waggie Z, Reynolds L, Argent A. Transport of critically ill children in a resource-limited setting. Intensive Care Med. 2003;29:1547-54. (Pubitemid 37153600)
86. Lee LL, Yeung KL, Lo WY, Lau YS, Tang SY, Chan JT. Evaluation of a simplified Therapeutic Intervention Scoring System (TISS-28) and the Modified Early Warning Score (MEWS) in predicting physiological deterioration during inter-facility transport. Resuscitation. 2008;76:47-51. (Pubitemid 350235085)
87. Lees M, Elcock M. Safety of interhospital transport of cardiac patients and the need for medical escorts. Emerg Med Australas. 2008;20:23-31. (Pubitemid 351191382)
88. Ligtenberg JJ, Arnold LG, Stienstra Y, et al. Quality of interhospital transport of critically ill patients: a prospective audit. Crit Care. 2005;9(4):R446-451.
89. Lim MT, Ratnavel N. A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service. Pediatr Crit Care Med. 2008;9:289-93. (Pubitemid 351677682)
90. Limprayoon K, Sonjaipanich S, Susiva C. Transportation of critically ill patient to Pediatric Intensive Care Unit, Siriraj Hospital. J Med Assoc Thai. 2005;88(suppl 8):S86-S91. (Pubitemid 43175626)
91. Linden V, Palmer K, Reinhard J, et al. Inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation-national and international experience. Intensive Care Med. 2001;27:1643-8. (Pubitemid 33027962)
92. Moss SJ, Embleton ND, Fenton AC. Towards safer neonatal transfer: the importance of critical incident review. Arch Dis Child. 2005;90:729-32. (Pubitemid 40922507)
93. Uusaro A, Parviainen I, Takala J, Ruokonen E. Safe longdistance interhospital ground transfer of critically ill patients with acute severe unstable respiratory and circulatory failure. Intensive Care Med. 2002;28:1122-5. (Pubitemid 34985237)
94. Bair AE, Smith D, Lichty L. Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers. J Emerg Med. 2005;28:403-7. (Pubitemid 40523687)
95. Di Russo SM, Sullivan T, Risucci D, Nealon P, Slim M. Intubation of pediatric trauma patients in the field: predictor of negative outcome despite risk stratification. J Trauma. 2005;59:84-90; discussion 90-1.
96. Fakhry SM, Scanlon JM, Robinson L, et al. Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma. 2006;60:997-1001. (Pubitemid 43778631)
97. Jemmett ME, Kendal KM, Fourre MW, Burton JH. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med. 2003;10:961-5. (Pubitemid 37093199)
98. Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician-verified out-of-hospital intubation: miss rates by paramedics. Acad Emerg Med. 2004;11:707-9. (Pubitemid 38736235)
99. Mackay CA, Terris J, Coats TJ. Prehospital rapid sequence induction by emergency physicians: is it safe? Emerg Med J. 2001;18:20-4. (Pubitemid 34070832)
100. Newton A, Ratchford A, Khan I. Incidence of adverse events during prehospital rapid sequence intubation: a review of one year on the London Helicopter Emergency Medical Service. J Trauma. 2008;64:487-92. (Pubitemid 351640467)
101. Parwani V, Hoffman RJ, Russell A, Bharel C, Preblick C, Hahn IH. Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques. Prehosp Emerg Care. 2007;11:307-11. (Pubitemid 47037231)
102. Pratt JC, Hirshberg AJ. Endotracheal tube placement by EMT-Basics in a rural EMS system. Prehosp Emerg Care. 2005;9:172-5. (Pubitemid 43205591)
103. Svenson JE, Lindsay MB, O'Connor JE. Endotracheal intracuff pressures in the ED and prehospital setting: is there a problem? Am J Emerg Med. 2007;25:53-6. (Pubitemid 44854383)
104. 2 during air medical crew intubations? Prehosp Emerg Care. 2006;10:363-8. (Pubitemid 43995581)
105. Wang HE, Cook LJ, Chang CC, Yealy DM, Lave JR. Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation. 2009;80:50-5.
106. Wang HE, Kupas DF, Paris PM, Bates RR, Costantino JP, Yealy DM. Multivariate predictors of failed prehospital endotracheal intubation. Acad Emerg Med. 2003;10:717-24. (Pubitemid 36835067)
107. Wang HE, Lave JR, Sirio CA, Yealy DM. Paramedic intubation errors: isolated events or symptoms of larger problems? Health Aff (Millwood). 2006;25:501-9. (Pubitemid 43529572)
108. Wang HE, Sweeney TA, O'Connor RE, Rubinstein H. Failed prehospital intubations: an analysis of emergency department courses and outcomes. Prehosp Emerg Care. 2001;5:134-41. (Pubitemid 32322112)
109. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care. 2007;11:213-8. (Pubitemid 46514915)