Reportable Incidents

     You are the newly appointed safety officer for the Tri-Community Volunteer Ambulance Squad, and the assignment seems to be under control while you take various OSHA-type classes and learn the ropes. One night, you are awakened by a phone call from a panicky squad member, who tells you, "I was involved in an accident with one of the trucks and the patient was thrown from the stretcher. I think he's hurt really bad... who do I need to notify about this?" You think you need to notify the state EMS office, but you're not sure how or under what time frame. You wonder if the regional EMS authority has a reportable-incident policy, and think, "Nobody told me about all this stuff when I agreed to become the safety officer. Why don't we have a written policy for things like this?"

     Almost every state's guiding EMS legislation and/or governing authority has a definition of a reportable incident (sometimes referred to as a reportable event), as well as a time frame in which said incidents need to be reported. (Depending on the seriousness of the incident, this can be within 24 hours or five days.)

     Some broad areas that reportable incidents encompass include:

• Medication errors and omissions such as inappropriate drug, inappropriate dose, inappropriate rate, inappropriate route, or failure to medicate at all.
• Failure to assess and treat a patient in compliance with regional and/or state protocols or guidelines, or failure to appropriately assess, initiate or administer care in accordance with statewide treatment protocols resulting in serious injury or patient death.
• Injuries or death to a patient while in EMS' care.
• Inappropriate use of a medication or device that results in serious injury to the patient.
• EMS vehicle accident, whether or not it results in injury or death to a patient, crew member or other person.
• Allegation or suspicion of drug and/or alcohol use by an EMS provider while on duty.

     Additional reference material is available in the Commonwealth of Massachusetts' Office of Emergency Medical Services Administrative Requirements manual and at the New York State Department of Health's Office of Emergency Medical Services website: www.health.state.ny.us.

     Your EMS agency needs to institute policy and procedure to ensure it is following all applicable federal and state rules and mandates, as well as protecting itself from liability following an incident. The following statement from a San Francisco policy titled "Performance Management Reporting" provides a simplified definition of some applicable reportable incidents that is easy to follow and may help reduce risk:

     "Reportable events include, but are not limited to:

1. Use of intoxicants or impaired ability due to alcohol or drugs while on duty as an EMS provider.
2. Clinical acts or omissions that may be considered negligent or possibly contributed to poor patient outcome.
3. Deviation from EMS policy or protocol that may result in poor patient outcome.
4. Any act or omission that constitutes a threat to public health and safety."

     When designing a policy for reportable incidents, it is important to consider the following:

• Defining reportable incidents is the most important part of the process. Although your state or local regulatory body may have defined possible or vague reportable incidents, it is your responsibility to clearly define for your agency what is reportable and what is not.
• Clearly establish a chain of command. This will become the blueprint for notification.

     Your policy statement may read something like this:

• In the event of a reportable incident, immediate notification must be made to the on-duty supervisor and the safety officer.
• File an incident report with the safety officer (may be placed in a mailbox) immediately upon return to the ambulance station.
• Upon notification of a reportable incident, the safety officer will read the incident report, determine the severity of the incident and whether it is reportable to the region or state.
• The safety officer will interview the person who filed the incident report to gain first-hand perspective.
• The safety officer will notify the chair of the board and chief supervisor/captain within 24 hours for any report filed, regardless of determination.
• The safety officer will file all necessary reports to county, state and federal authorities within seven business days.
• Once all reports have been filed and all information gathered, the safety officer will meet with the Quality Assurance Committee for an informal discussion and possible creation of policy or procedure to reduce the risk of a similar incident repeat.

     The New Jersey Department of Health and Senior Services Office of Emergency Medical Services has developed a template SOP for EMS agencies to utilize when developing their own agency-specific reportable incident SOPs. Section H, subsection 1 of this document includes the areas mentioned above (including death of a patient under unusual circumstances, fire in an EMS vehicle, providers acting outside their scope of practice and other areas), as well a timeline for when incidents need to be reported and followed up on.

     There are some common themes in the above information to consider when instituting a reportable-incidents policy. First, each agency needs to appoint or hire a safety officer to serve as a point person for reportable incidents. This can be considered an additional duty to an already established position or a sole job description. Notice the word "immediate" as a theme that runs through that policy. Although there is some flexibility in this regard based on the seriousness of the incident, for the purposes of this article, the word immediate is defined as "as soon as possible." If a defibrillator shocks a patient in sinus tachycardia, immediate reporting of the incident may save someone's life. Likewise, if an ambulance blows a tire and rolls over, an immediate report to the ambulance manufacturer may save another provider's life.

     Remember to keep your agency's reportable-incident policy current. The safety officer should periodically review county, state and federal guidelines to ensure that agency policy is in compliance with, and does not contradict, higher authority. Take particular note that phone numbers may change, positions within the organization may become obsolete or the policy itself may not be current and therefore must be changed to fit state and federal trends or standards. Staying current with a reportable-incident procedure will help ease what can be a complex, bureaucratic and cumbersome process.

     Finally, it is a good idea to attempt to exercise the policy. During regular drills or agency downtime, give a paramedic a scenario to act through, or test the policy during a mass casualty incident exercise. Most of your organization's top brass will be involved in the MCI exercise, which also makes them accessible.

     The process of exercising a policy has a number of components. The first step is a tabletop exercise. Gather the main players and talk through a scenario. Using maps, scaled models of the city/location, communications and forms to "act" through the policy will assist in ensuring its effectiveness.

     The next phase is the announced exercise. Form a scenario, hold a pre-briefing of what actions will take place and then activate the exercise using a prescribed timeline. Finally, conduct an unannounced exercise, where the exercise evaluation team is the only group that knows the scenario and expected timeline.

     Through each stage of exercise, perform quality assurance and debrief all participants to determine what worked, what could be improved and if any changes are needed. Once exercises have been completed and evaluated, make necessary modifications based on the QA sessions and implement the plan. Note: This method of exercise and evaluation has many more components when dealing with reportable incidents. Exercises can be scaled down to focus on the policy being discussed.

     Whether you are aware of them or not, significant legal ramifications go hand in hand with these reportable incidents. Many entities, including federal agencies like OSHA or state organizations like your state EMS office, mandate such reporting, and you and your EMS agency may find yourselves in some trouble if you do not report certain events, intentionally or not. It is imperative to include state and federal reporting-incident regulations when designing your policy. Ensure that steps and measures outlined in your policy don't conflict with those regulatory bodies that govern your organization. One of the more important elements of the legal implications is that, in most states, self-critical analysis (also known as QA/QI) is exempt from discovery and is often protected under state law and federal privacy acts. Be sure to check with your jurisdiction about what items are or are not protected.

     No matter your level of training and preparedness, reportable incidents of all varieties are bound to happen to your EMS agency. One of the most important steps prior to these occurring is knowing the mandates (state, regional and/or local) in specific regard to reporting. This knowledge will allow you to adequately prepare your providers and your EMS agency in the event of an incident.

     Preparation will ultimately help reduce providers' apprehension about the reporting process. Reporting problems and growing from them will ensure better-quality prehospital care in the future.

     Raphael M. Barishansky, MPH, EMT-B, is program chief of Public Health Emergency Preparedness for the Prince George's County (MD) Health Department, and a member of EMS Magazine's editorial advisory board. Contact him at rbarishansky@gmail.com.

     Daniel E. Glick, BPS, AEMT-CC, is the coordinator for Emergency Management Programming at Schenectady County (NY) Community College and an aeromedical evacuation operations officer for the 139th AME Squadron, New York Air National Guard. Contact him at deg3142@gmail.com.