Preventing Medical Errors: The Bottom-Up Approach to Just Culture

In this three-part series, EMS World examines medical errors and preventable harm in the prehospital and in-hospital settings. Medical errors are preventable events caused by procedural or communicative mistakes resulting in physical harm to or death of the patient. This series covers root causes of medical errors and how to implement measures to prevent them from occurring. The criticality of this systemic problem is indicated by a 2016 study conducted by Johns Hopkins University School of Medicine, which contends that medical errors are the third-leading cause of death in the U.S., citing “communication breakdowns, diagnostic errors, poor judgment, and inadequate skill” as primary causes of error. The study’s data revealed an estimated 400,000 deaths occur every year in the U.S. as a result of medical error.

Attending the 2019 EMS World Expo? Check out the hands-on workshop EMS Patient Safety Leadership Monday, October 14, in New Orleans, La., led by Lee Varner. You can also register for his webinar, "The Buck Stops Here: A Leader’s Duty to Patient Safety," here.

In Part 2 of the “Preventing Medical Errors” series, Lee Varner, MSEMS, CPPS, EMT-P, director of the Center for Patient Safety (a nonprofit dedicated to reducing preventable harm in healthcare), shares his recommendations for creating an effective safety culture within EMS agencies. If you look at most healthcare organizations—hospitals, ambulatory care, primary care physician practices, long-term care—they have built-in safety standards, regulations, and accreditations to maintain, many of which are linked to reimbursement. But in EMS you’ll be hard-pressed to find any of these established.

“Other healthcare settings have those measures in place but still have medical errors. Thinking about the unpredictable, chaotic environment we work in, we’re really in a prime situation to make mistakes,” says Varner. “We as a profession are still trying to understand what this term ‘patient safety’ means because it’s not part of our everyday language or vocabulary.”

Of course, most of us enter EMS because we want to help people, so the notion of valuing patient safety seems obvious. But it’s not about accusing providers of being lackadaisical in their care or intentionally causing harm—it’s the recognition that most clinical errors are simply a result of process failures and a breakdown of the system.

“Human beings make mistakes. We are fallible, and that’s one of the reasons why we see harm reaching patients in healthcare,” says Varner. Personal biases and complacency can make us more error-prone if we don’t check them at the door. When responding to a citizen’s assist call, for example, you might leave your equipment behind, assuming you’ll just help someone get back into bed, only to enter the house to find the patient in full cardiac arrest. “We begin to impose some of our own beliefs as to what we think is important, not fully thinking about the overall situation. This is often highly reflective of an organization’s culture and how the clinician works within that system of care.”

“It’s about being proactive rather than reactive to reduce preventable patient harm,” says Varner. This principle is considering the defects in the design of our systems of care, he says, especially when taking into account human factors and the quality of an organization’s safety culture. Despite these hurdles, Varner believes the industry is exhibiting a growing interest in improving patient safety through actionable steps, such as studying metrics of adverse events and near-misses, creating action plans according to that data, and finding the funding to do so with better reimbursement models.

He describes the diffusion of innovations theory, represented by a bell curve that depicts how people accept change: innovators and early adopters comprise the beginning of the curve, the early and late majority make up the top of the curve as those who “wait and see,” while laggards, those who change only when incentivized or forced, are placed at end of the curve.

Varner is encountering more EMS leaders falling into the category of early adopters as they recognize the outcomes are worth the time and resources utilized to ensure the safest care possible for their patients. Agencies might take the EMS Safety Culture Assessment survey, from the Center for Patient Safety. This is something that hospitals do regularly to assess their safety culture by measuring areas like communications, patient handoffs, teamwork, response to error, and fatigue. This helps evaluate the organization’s culture and identify potential areas of risk and where to start improvement projects. Preliminary national data from CPS shows EMS organizations score the lowest in communications, staffing, work pressure, and pace, as well as openness or trust.

“If we can begin to understand those causal factors, we can then begin to build process improvement plans to deliver safer care,” he says. “We should remember the Latin saying of ‘First, do no harm,’” or primum non nocere.

Ask and You Shall Receive

Surveys can help your agency determine where to focus improvement efforts and evaluate your culture—if it’s just, employees can speak up when they notice certain practices that compromise the safety of patients without fear of punishment or humiliation and feel confident leadership will address the issue. Anonymous surveys are preferable, as they encourage transparency in responses. While some comments might be painful for leadership to read, useful information can be gleaned from them, says Varner.

“That’s where leaders should be looking—what should we know about the risks in our organization? It’s our frontline clinicians who typically know because they’re out there, day in and day out, so they’re able to identify things that keep them up at night that sometimes leaders don’t see or hear about because their culture may be negative.”

The need for openness in communication extends to hospital and long-term care settings as well, where Varner says the interdisciplinary relationships are sometimes weak and can impact how the patient gets treated. “Communicating with hospitals and long-term care is a huge problem,” he says. “If we’re going to one of these facilities and the staff isn’t listening to the EMS clinician, or they’re not taking a timeout to let the providers give a report, that’s not a safe practice. Likewise, EMS needs to do the same and listen to our other healthcare partners.”

To strengthen the relationship between EMS and hospital staff, leadership from both organizations must come together and ask what information is needed from each other to provide the best care for the patient. Creating a standardized process of exchanging information will benefit both patients and providers. It’s also helpful to understand and respect each other’s roles and get to know each other better as individuals.

“Lack of or the breakdown of communication is one of the leading causal factors in clinical errors,” Varner says. “It’s important to have a strong, open degree of communication and teamwork when we’re taking care of patients. When that begins to break down, it’s really the patient who’s at risk.”

Back to Basics

“In our formative processes, we haven’t talked a lot about patient safety in our industry,” says Varner, due in part to the strong emphasis placed on workforce safety as the industry developed and we realized providers were working under dangerous circumstances. While personal safety is a priority, we can’t forget that we’re in the business of protecting patients, too. In most cases we don’t discuss patient safety in EMT and paramedic school.

“Other high-consequence, high-risk industries—like commercial aviation, nuclear power, the shipping and mining industries—figured this out years ago. They realized that to better manage risk, they needed to have a positive safety culture.” Those industries quickly went to work on integrating the “preoccupation with failure into everything that they do.”

This is exactly what EMS should be doing. Education can set the foundation to embed that cultural mind-set into students while also encouraging medics in the field now, whether rookie or veteran, to pause, think, and ask themselves, Is what I’m doing to my patient safe? What can go wrong? With the advance of simulation training, we can also help students learn about clinical errors and the many causal factors behind them.

“There’s a really strong cultural component to this, and we need to look at it on the industry level and organizational level of every EMS agency,” says Varner. “If you don’t have a learning culture, it’s going to be really hard to make changes within that organization—that’s part of the just culture model.

“When we talk about culture, it consists of four things: our attitudes, our perceptions, our beliefs, and our values,” he says. These frequently influence and shape our safety behaviors. However, leaders of your organization and your colleagues might have different ideas of what is considered safe. This is why measuring the safety culture is invaluable to improvement—it’s unbiased, so it gives you an accurate interpretation of your culture.

While utilizing surveys for safety culture is voluntary, it might not be for long. As EMS matures and moves towards more value-based care, Varner believes the industry will be held to patient safety standards and expectations akin to our healthcare allies. Being cognizant of changes from payors and regulators and taking preventive action now will save you time and trouble later. “As an industry, we need to take ownership of this; otherwise we’ll have an imposer coming from the outside telling us how to do this,” he says.

Varner suggests following your chain of command if your immediate supervisors are unwilling to listen to concerns about patient safety. Approaching your medical director to discuss ideas about improving safety culture can be the next step; if necessary, seek counsel from your board of governance. Failing to address the causes of mistakes in healthcare doesn’t only affect the patients—providers feel the impact of the harm too.

“There’s something called the second victim phenomenon where clinicians become impacted by an unanticipated event,” says Varner. “When we make a mistake, we can be impacted by that for the rest of our lives because we care so much.”

Varner has seen EMTs, paramedics, physicians, and others either leave their professions or fall into depression. In the worst cases the emotional toll can lead to suicide. “Most mistakes are not the clinician’s fault, but they often end up taking the responsibility for them. This is part of the blame and shame we see everywhere in healthcare. We want people to get support and not see them slide into this cycle of mental health conditions.”

All of this work takes time, says Varner—there’s no quick fix to improving patient safety, but we can start by improving education, involving our medical directors, and collaborating with healthcare partners to provide safe patient care. Instead of punishing providers for their errors, we have to look at our process problems.

“Having a plan in place, measuring safety culture, and building a culture that is not based around blame is the direction we need to go in,” he says. “We need leadership support to set the vision and provide the necessary framework to make it happen and make it successful.”

Lee Varner is the director of EMS services at the Center for Patient Safety. Lee holds both a bachelor’s and a master’s degree of science in EMS from Creighton University in Omaha, Nebraska. Lee has been a flight paramedic for a hospital-based air medical service and also served at the St. Charles County (Mo.) Ambulance District for over 20 years. He then became the EMS Coordinator for Mercy Hospital in St. Louis and later started his career at the Center for Patient Safety. Lee holds certifications as a Just Culture trainer and as a Professional in Patient Safety. In the past five years, he has developed innovative approaches and campaigns to reduce preventable patient harm in EMS. This includes the EMSFORWARD campaign and codevelopment of the EMS Safety Culture Assessment. Lee is a founding member of the National EMS Safety Council, an active member of the NAEMT, and serves on the CAAS Standards and Revisions Committee.

Valerie Amato, NREMT, is assistant editor of EMS World. Reach her at vamato@emsworld.com.