An unannounced EMS supervisor’s visit could mean an atta-boy or a social visit, but more often than not, it means that there was a call worth discussing and a simple phone call wouldn’t suffice.
Recently the supervisor stopped by to discuss a call in which my partner and I had opted to administer a second dose of adenosine after the first had failed to convert a narrow complex tachycardia.
After the first dose, the patient’s heart slowed optimistically, revealing a wavy baseline that looked suspiciously like atrial flutter, before returning to its original rate. I reasoned that a second dose might still be effective in this rhythm. My partner felt that it couldn’t hurt to try. We were both wrong
We delivered our patient, with his still-fluttering heart, to the emergency room staff and went on our way. Now, reclining in a squeaky chair in the lieutenant’s office, I needed to answer for my clinical decision.
I’ve sat in on my share of quality assurance (QA) and quality improvement (QI) meetings. They are rarely comfortable. But I have learned to approach them with less anxiety and a genuine appreciation for their necessity. If your palms sweat and your heart rate soars at the prospect of meeting with your QA/QI officer, let me offer these tips.
1. Recognize the essential nature of errors in skill acquisition
It’s easy to walk in the door with the idea that you’ve done something wrong and the meeting is a punitive result. You made a mistake and it’s time to pay. This idea is fueled by our crime and punishment culture.
Let go of the idea that clinical errors are a result of your inadequacy, bad judgement or lack of knowledge. While it’s true that all of those things can be contributing factors to clinical errors, it’s also true that everyone who practices medicine makes errors. Every care provider makes mistakes and you are no different.
Not only are mistakes universally common, they are essential to our learning. And that’s the real goal of any QA/QI meeting. Identify the mistake, learn and improve.
2. Be honest with yourself and your QA/QI officer
If we walk into a meeting with a crime-and-punishment mentality, our natural response is defensiveness. We rationalize, “I’m under attack here. I need to defend myself.”
Defensiveness makes sharing and learning almost impossible. Begin the meeting with a dialogue about what happened on the call and what led to the decision or action that is in question.
Recall as best as you can your mindset at the time of the call. Was it a good day or a bad day on the rig? Were you and your partner working well together? Who else was on the call? How was your rapport with the patient? Were you tired? When you made this decision or committed this error, did you do so with confidence or uncertainty? Walk through your thought process and share it with everyone in the meeting.
If you were uncertain about what to do, say that. Everyone in the room understands uncertainty. If you debated multiple treatment options, discuss them and talk about why you chose the path you took.
Make every effort to be accurate and complete. Everyone in the room needs to understand what happened. You are the best person to describe the incident. They have your paperwork, but they need your story.
There is nothing more frustrating for your QA/QI officer than to feel like they have to ask question after question to get you to reveal the basic details of the call. You aren’t on a witness stand and this isn’t a court room. Tell the story start to finish, with all the details.
3. Stay curious and self-motivated
Now that we’ve agreed that you aren’t going to be defensive. Two great attributes to bring to the meeting are curiosity and self-motivation.
First, be curious. Talk about the patient’s condition. What can be learned about the patient’s presentation and how it related to their illness or injuries? Were there signs or symptoms that were missed? If so, was it an issue with your assessment or your understanding of the patient’s condition?
Being curious isn’t the same as asking a lot of questions as a form of resistance. Being curious means that you genuinely want to better understand what happened.
Second, self-motivation shows that you are the driving force behind your own learning and development. Don’t wait for your leadership or management team to assign you an improvement plan.
Regardless of your decisions on the call, ask yourself what could have gone better and begin designing your own course of improvement. You should already have a plan before your QA officer asks for a meeting. The real question then becomes, how will you modify your current improvement plan based on this new information?
4. Focus on what was the most clinically appropriate decision
Sometimes our QA/QI meetings can be overly dogmatic and rule-focused. In these cases, try to steer the conversation to what was and was not clinically appropriate. When in doubt, simply ask the question, “Do you feel my decision went against our rules and guidelines or do you feel that I did something clinically inappropriate?”
Rule-based errors are sometimes the easiest to fix. You were supposed to call the physician before administering a medication. You were supposed to apply restraints. You opted to not follow a rule or disregarded a guideline. Your organization would prefer that, in this circumstance, you follow that rule.
Clinically inappropriate decisions require more follow-up. What was the missing knowledge or skill deficit that led you down this road? What gaps of knowledge or skill should be remedied to make a similar event less likely?
Find your weakness and begin the process of improvement. Self-improvement is a never ending cycle. Don’t fight it.
5. Reject hindsight bias
Hindsight bias is the tendency to view the events of the past with a bias for what we now know in the present and concluding that our current understanding should have been obvious. Here are a few examples.
- You brought a chest pain patient to the hospital without calling a cardiac alert. The patient was found to be having an MI. Your decision to not call the alert is judged as wrong based on the hospital’s finding.
- You transported a patient with altered mentation. Your presumptive diagnosis was an accidental overdose. The patient was found to be septic. Now that the diagnosis is known, you are judged to have missed several treatment priorities due to the incorrect diagnosis.
In cases when you think that hindsight bias is factoring too heavily into the conversation, try to steer the discussion back to the facts that were known at the time of treatment. Your detailed patient care report paints a good picture of the clinical presentation that you were faced with while the call was in motion.
Walk through your assessment notes and discuss which of your findings were consistent with the ultimate diagnosis and which things didn’t fit the final clinical picture. Were there enough clues to lead you down the right road? If so, own up to it. If not, suggest that perhaps the judgement of your care is being too heavily influenced by hindsight bias.
6. Consider a QA preemptive meeting
The very best QA/QI meetings are the ones you initiate. It doesn’t need to be formal. Drop by the QA office or call on the phone. Try something like this:
“Hey, I had a really challenging call and I’d like to talk to you about it. I think I went down the right treatment road but I’m not sure. I know I can gain some more insight by running it by you. Let me know when you have a minute for the whole story.”
If you are uncertain about a decision that you made, it’s always better to give your QA officer person a heads-up before the patient care report reaches their desk or a doctor calls. Invite your QA officer to be an educator, resource and mentor.
7. Offer to present a case review
If your bad call was filled with valuable learning experiences, offer to present it as a case review. Don’t learn and gain experience on an island. Once you commit to teaching the subject that tripped you up during patient care you’ll be highly motivated to expand your knowledge in that area. Presenting your patient case isn’t a punitive exercise. It’s a group learning opportunity.
Some people see their quality assurance manager’s job as that of carrying around a flashlight and shining it on people’s mistakes. I say bring your own flashlight to the party. Shine it right on yourself and say, “Look what I did!”
Then explain in detail what you learned. If you do this right, you’ll end up looking like the smartest person in the room.
After my sit-down with the EMS supervisor I went to the computer and started researching adenosine use in various forms of tachydysrhythmias. I reviewed many of the things I already knew and learned way more than I was ever taught, which I shared with other medics. I’m thankful that my organization cared enough to recognize the clinical error and bring it to my attention. I’d like to think that I’m improving as a paramedic and errors, however uncomfortable, are an essential part of that process.
