Cases With a Twist: Repetitive Risks

This inaugural column is dedicated to our peers who risk their lives to serve others daily. In this column we will explore cases in which things didn’t quite go as planned. Sometimes this means we were surprised by a clinical presentation, while others involve near-misses or adverse events. While we love EMS, the work we perform is often conducted in unpredictable and harsh environments with limited information and resources and high stress. EMS personnel are 2½ times more likely to be killed on duty, and five times more likely to suffer a transportation-related injury, than the average worker.¹ We hope this column will help promote an open, honest and timely process to communicate potential mishaps and promote a culture of safety in EMS operations.

This Month’s Case

After an emergent transport to the hospital, the crew was unloading the stretcher loaded with a roughly 200-pound critical patient in congestive heart failure. Crew member #1 was at the foot of the stretcher, operating the manual control, while crew member #2 was on the patient’s right side, watching and ready to catch the wheels.

As expected, with ER staff watching as they met the ambulance in the garage, the crew was moving quickly to get the critical patient inside. Crew member #1 began to give a quick report while starting to pull back on the stretcher. The hospital has a slightly uneven garage floor (to allow for drainage in the center), and the vehicle and stretcher were slightly tipped to the patient’s left side.

As the crew pulled the stretcher out, the safety bar missed the safety hook. The stretcher came out of the back of the ambulance rapidly, with its wheels still retracted.  Crew member #1 at the foot of the stretcher tried to hold the weight. Unfortunately the stretcher tipped toward the left, and the patient reached out to the left side as crew member #2 (on the patient’s right side) pulled up, trying to help prevent the stretcher from hitting the ground. Momentum shifted to the left side.

To complicate matters, this stretcher was equipped with a canvas basket behind the head. When the stretcher began tipping out of balance, a worn and loose strap caught the safety hook, making it harder for both crew members to maintain the stretcher upright.  

At this point the stretcher twisted and inverted, almost completely falling to the ground.  The patient struck their head, face and upper left shoulder on the jagged ambulance bumper first, then the floor. Assisted by the ER staff, the patient was rolled and placed on a long spine board with cervical precautions and then quickly moved into the critical care room.

Crew member #2, leaning while trying to lift, immediately felt severe back pain and fell forward, striking their head on the overturned stretcher and sustaining an inch-long laceration to the forehead.

The patient died of heart failure shortly after admission. On review the traumatic injuries, while serious and possibly having delayed care, were not found to be directly responsible for the patient’s death. Crew member #2 sustained a herniated L5-S1 low-back injury that required a laminectomy and extensive rehab, and continues on light duty with the goal of returning to work in the field.

Root Cause Analysis

When analyzing adverse events, safety experts talk about gaps or holes in safety practices lining up to cause a “perfect storm” that results in injury. (See the “Swiss cheese model” explained here: https://psnet.ahrq.gov/primers/primer/21/systems-approach.)

In this case the crew, with a combined 14 years of experience, acted like so many other crews would. With a critical patient’s best interest in mind, they moved quickly performing a routine task—unloading the stretcher, a procedure they have completed thousands of times without mishap. They were neither disregarding safety nor acting recklessly. In the blink of an eye, they became distracted with reports to the ER staff and relied on a safety hook that had never failed them.  

It is common for us to be complacent and disregard risks during repetitive tasks that have never caused us harm. Like our use of stretchers on every call, pilots will take off and land an airplane on every flight. And like aviation, where most crashes occur on take-off and landing, we also know most injuries to providers and patients will occur during stretcher loads and unloads.  Have you ever thought, I don’t need to wear my seat belt, I’m just driving down the block to the store? When “it hasn’t happened to us,” we can think It doesn’t happen to me. Our complacency leads us to slip, then trip.

Nonpreventable Factors

The single hook, combined with a stretcher safety bar that is curved, combined with a garage that is tilted, combined with straps from equipment baskets, combined with an unload procedure that requires holding weight until wheels descend and lock, is a system design disaster waiting to happen.

Preventable Factors

Crew distraction, lack of communication during a critical task, moving too quickly and disregarding risks are all elements that could have been mitigated in this case.

Lessons

This event is as tragic as it is common. Clearly we need systems that have improved safety design. Help may be on the way from stretcher manufacturers offering no-lift systems. In the meantime, what can you do to prevent this from happening on your next call?

We are big fans of crew resource management (see sidebar). In keeping with aviation’s “red rule” when potential risks exist, it is essential that we stop (or at least slow down enough to think about the procedure), perform a cross-check with a partner, follow a clear checklist, use clear verbalization of keywords, and repeat back confirmation (closed loop communication). Maintaining a sterile cockpit could also prevent unnecessary distraction. In this case identifying an environmental hazard (tilted garage floor) and waiting for a third person to help is also possible.

Improving safety parameters, such as removing loose straps, placing two safety hooks and ensuring the stretcher bar is updated to be flat, will help mitigate some risks.
Standardizing the process of loading and unloading would be the single greatest mitigator of risk in this case. Streamlined and vetted processes have been proven to mitigate almost all errors.

From simple procedures such as ensuring a door is locked before an airplane takes off to complex crash landings into a river, cross-checks with a standardized checklist have saved many lives. Remember, slow is smooth, and smooth is fast.

CRM Tips

this column will feature a monthly tip on Crew Resource Management (CRM) principles and techniques that apply to the cases we present.  

CRM techniques have led to improved communication, teamwork and safety in the military, commercial aviation and now EMS/fire agencies.

In this inaugural column, patients and providers were injured in a stretcher mishap. In aviation most crashes occur on take-off and landing. If we apply this principle to EMS, let’s imagine a systematic process to improve stretcher loading (take-off) and unloading (landing):

• Sterile cockpit—During take-offs and landings, crews are silent unless there is a concern for safety. In our EMS case, we do not want to create distractions until critical stretcher procedures are completed. These might include wheels being up and the stretcher being latched.
• Key words—The critical step in stretcher unloading is to ensure the wheels are down and locked.
• Checklists—For procedures we know might injure a patient or ourselves, we have to take additional steps to reduce risks. One of these is to pause, review key steps in a checklist, and read back these steps for a second person to confirm we have not missed anything. For procedures that carry excess risk— like aviation’s “red rule”—checklists force crews to stop, read back and ensure we have critical elements covered.

Why Do We Need This Column?

Recent studies report between 98,000 and 210,000 deaths each year are due to preventable medical errors.^2–4 We know that errors in areas like medication administration, airway management, assessment errors and patient falls are not just happening in hospitals. These same errors occur in ambulances, but providers are afraid to report them for fear of being dismissed, and agencies are afraid to report them from fear of being sued. Unfortunately, without reporting or tracking these errors, we cannot understand the depth of the problem or create systems to improve our safety.

In 2013, responding to a request from the National EMS Advisory Council (NEMSAC), the National Highway Traffic Safety Administration (NHTSA) collaborated with the American College of Emergency Physicians (ACEP) to publish the Strategy for a National EMS Culture of Safety (www.emscultureofsafety.org). This landmark document outlines the need, framework and steps for EMS to implement major operational changes that will lead to improved safety.

To become more reliable we must implement just culture. Learning from our mistakes so we do not repeat them is a key component of this process. We must make it safe to report errors without fear of reprisals and analyze the root cause of the adverse event. Like aviation, we need to focus on systems of safety, not blaming individuals.  

The Center for Leadership and Research (CLIR), in collaboration with the National Association of EMTs (NAEMT), has set up an international reporting website and database to track these errors at www.emseventreport.com. The brainchild of paramedic Gary Wingrove, this tool allows EMS providers to anonymously report near-miss or actual adverse events without fear of punishment. 

In this column we intend to report on cases where things simply didn’t go as planned. We will hide details to protect the privacy of those who share these events, but we want to help create a national culture of safety that is not afraid to shed light on near-miss or adverse events. We are committed to facilitating honest and prompt reporting so that others will learn from them and avoid them.  Send comments and feedback to editor@emsworld.com.

Report Events

Please help us identify errors and near-miss events that affect the safety of EMS providers and patients. Report events anonymously at www.emseventreport.com.

E.V.E.N.T. is an anonymous tool designed to improve the safety, quality and consistent delivery of EMS. The data collected will be used to develop policies, procedures and training programs. A similar system used by airline pilots has led to important system improvements based upon pilot-reported “near-miss” situations and errors.

Video Challenge

Can you come up with a video that demonstrates sterile cockpit, key words and use of a checklist for safe loading and unloading of the stretcher? If you do, please send the link to editor@emsworld.com. Our partners at North Ambulance and Jones and Bartlett Learning filmed this “stretcher cross-check” seen here: EMSReference.com/checklists.

Editor’s Note

Cases are obfuscated and amalgamated to protect patient privacy and provider anonymity. While staying as true as possible to the actual event, creative license is used to better explain the lesson(s) in the case.

References

1. Braithwaite S, et al. Strategy for a National EMS Culture of Safety; p 6, www.emscultureofsafety.org.

2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Safety, 2013 Sep; 9(3): 122–8.

3. Institute of Medicine. To Err is Human, https://iom.nationalacademies.org.

4. Department of Health and Human Services Office of Inspector General. Adverse Events in Hospitals: National Incidence Among Medical Beneficiaries, https://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.

Bibliography

Hobgood C, XIe J, Winder B, Hooker J. Error Identification, Disclosure, and Reporting: Practice Patterns of Three Emergency Medicine Provider Types. Acad Emerg Med, 2004; 11: 196–9.

Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics. Prehosp Emerg Care, 2000; 4: 253–60.

Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke, 1995; 26: 937–41.

Rittenberger JC, Beck PW, Paris PM. Errors of omission in the treatment of prehospital chest pain patients. Prehosp Emerg Care, 2005; 9: 2–7.

Vilke GM, Tornabene SV, Stepanski B, et al. Paramedic self-reported medication errors. Prehosp Emerg Care, 2006; 10: 457–62.

David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.

Will Krost, MBA, NRP, is a fourth-year medical student and a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences.  He has over 23 years of experience in EMS operations, critical care transport and hospital administration.