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Introduction of a Prehospital Critical Incident Monitoring System—Final Results

Published online by Cambridge University Press:  28 June 2012

Julian Stella ,
Bruce Bartley  and
Paul Jennings
Julian Stella*
Affiliation:
Emergency Medicine Specialist, Geelong HospitalEmergency Department, Barwon Health, Victoria, Australia
Bruce Bartley
Affiliation:
Emergency Medicine Specialist, Geelong HospitalEmergency Department, Barwon Health, Victoria, Australia
Paul Jennings
Affiliation:
Senior Operations Officer, Rural Ambulance Victoria, Victoria, Australia
*
Geelong Hospital, Emergency Department, Ryrie St Geelong 3220, Victoria, Australia E-mail: [email protected]
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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.

Keywords

ambulancemedical errorquality assurancerisk managementtrauma
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 25 , Issue 6 , December 2010 , pp. 515 - 520
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2010

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References

1.Hart, GK, Baldwin, I, Gutteridge, G, Ford, J: Adverse incident reporting in intensive care. Anaesth Intensive Care 1994;22(5):556–561.CrossRefGoogle ScholarPubMed
2.Runciman, WB, Edmonds, MJ, Pradhan, M: Setting priorities for patient safety. Qual Saf Health Care 2002;11(3):224–229.CrossRefGoogle ScholarPubMed
3.Runciman, WB, Sellen, A, Webb, RK, Williamson, JA, et al: The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993;21(5):506–519.CrossRefGoogle ScholarPubMed
4.Spigelman, AD, Swan, J: Review of the Australian incident monitoring system. ANZ J Surg 2005;75(8):657–661.CrossRefGoogle ScholarPubMed
5.Vinen, J: Incident monitoring in emergency departments: An Australian model. Acad Emerg Med 2000;7(11):1290–1297.CrossRefGoogle ScholarPubMed
6.Bolsin, S, Patrick, A, Colson, M, et al: New technology to enable personal monitoring and incident reporting can transform professional culture: the potential to favourably impact the future of health care. J Eval Clin Pract 2005;11(5):499–506.CrossRefGoogle ScholarPubMed
7.Brennan, TA, Leape, LL, Laird, NM, et al: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370–376.CrossRefGoogle ScholarPubMed
8.Leape, LL: Reporting of adverse events. N Engl J Med 2002;347(20):1633–1638.CrossRefGoogle ScholarPubMed
9.Localio, AR, Lawthers, AG, Brennan, TA, et al: Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 1991;325(4):245–251.CrossRefGoogle ScholarPubMed
10.Thomas, EJ, Studdert, DM, Burstin, HR, et al: Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38(3):261–271.CrossRefGoogle ScholarPubMed
11.Wilson, RM, Runciman, WB, Gibberd, RW, et al: The Quality in Australian Health Care Study. Med J Aust 1995;163(9):458–471.CrossRefGoogle ScholarPubMed
12.O'Connor, RE, Slovis, CM, Hunt, RC, et al: Eliminating errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care 2002;6(1):107–113.CrossRefGoogle ScholarPubMed
13.McDermott, FT, Cordner, SM, Tremayne, AB: Evaluation of the Emergency and Clinical Management of Road Traffic Fatalities in Victoria 1992-1993. Melbourne: Consultative Committee on Road Traffic Fatalities in Victoria; 31 March 1994.Google Scholar
14.McDermott, FT, Cordner, SM, Tremayne, AB: Evaluation of the Emergency and CLinical Management of Road Traffic Fatalities in Victoria 1993-1994. Melbourne: Consultative Committee on Road Traffic Fatalities in Victoria; 31 March 1995.Google Scholar
15.McDermott, FT, Cordner, SM, Tremayne, AB: Evaluation fo the Emergency adn Clinical Mangement of Road Traffic Fatalities in Victoria January-March 1996. Melbourne: Consultative Committee on Road Traffic Fatalities in Victoria; 30 September 1996.Google Scholar
16.McDermott, FT, Cordner, SM, Tremayne, AB: Evaluation of the Emergency and Clinical Management of Road Traffic Fatalities in Victoria 1996-1997. Melbourne: Consultative Committee on Road Traffic Fatalities in Victoria; 30 September 1997.Google Scholar
17.McDermott, FT, Cordner, SM, Tremayne, AB: A “before and after” assessment of the influence of the new Victorian trauma care system (1997-1998 vs 2001-2003) on the emergency and clinical management of road traffic fatalities in Victoria. Report of the consultative committee on road traffic fatalities in Victoria. Melbourne: CCRTF; 31 December 2003.Google Scholar
18.McDermott, FT, Cooper, GJ, Hogan, PL, et al: Evaluation of the Prehospital Management of Road Traffic Fatalities in Victoria, Australia. Prehosp Disaster Med 2005;20(4):219–227.CrossRefGoogle ScholarPubMed
19.McDermott, FT, Cordner, SM, Cooper, DJ, et al: Management deficiencies and death preventability of road traffic fatalities before and after a new trauma care system in Victoria, Australia. Journal of Trauma-Injury Infection & Critical Care 2007;63(2):331–338.CrossRefGoogle ScholarPubMed
20.McDermott, FT, Cordner, SM, Tremayne, AB: Evaluation of the medical management and preventability of death in 137 road traffic fatalities in Victoria, Australia: An overview. Consultative Committee on Road Traffic Fatalities in Victoria. J Trauma 1996;40(4):520–533; Discussion 533-535.CrossRefGoogle ScholarPubMed
21.McDermott, FT, Cordner, SM, Tremayne, AB: Consultative Committee on Road Traffic Fatalities: Trauma audit methodology. Aust N Z J Surg 2000;70(10):710–721.CrossRefGoogle ScholarPubMed
22.McDermott, FT, Cordner, SM, Tremayne, AB: Road traffic fatalities in Victoria, Australia and changes to the trauma care system. Br J Surg 2001;88(8):1099–1104.CrossRefGoogle Scholar
23.Aufderheide, TP, Pirrallo, RG, Yannopoulos, D, et al: Incomplete chest wall decompression: A clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques. Resuscitation 2005;64(3):353–362.CrossRefGoogle ScholarPubMed
24.Bair, AE, Smith, D, Lichty, L: Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers. J Emerg Med 2005;28(4):403–407.CrossRefGoogle ScholarPubMed
25.Beckmann, U, Gillies, DM, Berenholtz, SM, et al: Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care.[see comment]. Intensive Care Medicine 2004;30(8):1579–1585.CrossRefGoogle Scholar
26.Moss, SJ, Embleton, ND, Fenton, AC: Towards safer neonatal transfer: the importance of critical incident review. Arch Dis Child 2005;90(7):729–732.CrossRefGoogle ScholarPubMed
27.Rittenberger, JC, Beck, PW, Paris, PM: Errors of omission in the treatment of prehospital chest pain patients. Prehosp Emerg Care 2005;9(1):2–7.CrossRefGoogle ScholarPubMed
28.Boyle, M, Archer, F, Macdonald, R: Incident monitoring: A review of the literature and development of a pre-hospital model. Melbourne: Monash University; May 2002.Google Scholar
29.Stella, J, Davis, A, Jennings, P, Bartley, B: Introduction of a prehospital critical incident monitoring system—Pilot project results. Prehosp Disaster Med 2008;23(2):154–160.CrossRefGoogle ScholarPubMed
30.Beckmann, U, Bohringer, C, Carless, R, et al: Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review. Crit Care Med 2003;31(4):1006–1011.CrossRefGoogle ScholarPubMed
31.Barach, P, Small, SD: How the NHS can improve safety and learning. By learning free lessons from near misses. BMJ 2000;320(7251):1683–1684.CrossRefGoogle ScholarPubMed
32.Barach, P, Small, SD: Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ 2000;320(7237):759–763.CrossRefGoogle ScholarPubMed
33.Lawton, R, Parker, D: Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002;11(1):15–18.CrossRefGoogle ScholarPubMed
34.Nakajima, K, Kurata, Y, Takeda, H: A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. Qual Saf Health Care 2005;14(2):123–129.CrossRefGoogle Scholar
35.Boyle, MJ, Smith, EC, Archer, FL: Trauma incidents attended by emergency medical services in Victoria, Australia. Prehosp Disaster Med 2008;23(1):20–28.CrossRefGoogle ScholarPubMed
36.Donald, M, Paterson, B: Introduction of an electronic debrief and governance tool in prehospital care. Emerg Med J 2007;24(5):363–366.CrossRefGoogle ScholarPubMed
37.Fairbanks, RJ, Crittenden, CN, O'Gara, >KG, et al: Emergency medical services provider perceptions of the nature of adverse events and near-misses in outof-hospital care: An ethnographic view. Acad Emerg Med 2008;15(7):633–640.CrossRefGoogle Scholar
38.Beckmann, U, Runciman, WB: The role of incident reporting in continuous quality improvement in the intensive care setting. Anaesth Intensive Care 1996;24(3):311–313.CrossRefGoogle ScholarPubMed
39.Beckmann, U, West, LF, Groombridge, GJ, et al: The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesth Intensive Care 1996;24(3):314–319.CrossRefGoogle ScholarPubMed
40.Hayward, RA, Hofer, TP: Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. JAMA 2001;286(4):415–420.CrossRefGoogle ScholarPubMed
41.Semmens, JB, Aitken, RJ, Sanfilippo, FM, et al: The Western Australian Audit of Surgical Mortality: advancing surgical accountability. Med J Aust 2005;183(10):504–508.CrossRefGoogle ScholarPubMed
42.Wolff, AM, Bourke, J: Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review. Emerg Med J 2002;19(1):35–40.CrossRefGoogle Scholar