Updated May 11, 2016
From the dozens of ambulance crashes annually to the EMT in Hoboken, N.J., recently stabbed by a man reportedly demanding she hand over prescription drugs, the safety of EMS providers, patients and even bystanders is a growing area of concern for a broad array of stakeholders.
To begin tackling the issue of safety on an industry-wide scale, a committee of leaders in EMS and related fields recently released the “Strategy for a National EMS Culture of Safety,” a 97-page report that’s the culmination of three years of research, discussions and debate. The document, created by the American College of Emergency Physicians, identifies the safety issues facing EMS and describes the need to create not just safety programs, but a culture of safety that’s integral to every facet of EMS—from educating and training providers to the design and construction of vehicles to the way in which organizations handle and learn from mistakes. Written for policy-makers and leaders at the national, state and local levels, the document is intended to serve as a national framework, defining the scope of the problem and the core elements that a comprehensive safety strategy would encompass.
“This is a strategy document, not a safety manual or a how-to for the operational level,” explains Rick Murray, director of ACEP’s EMS and disaster preparedness department. “The Culture of Safety document identifies the components—whether it’s education for the providers, resources for agencies or the role of data—that would be part of a safety strategy.”
How the project came about
The Culture of Safety document emerged out of a 2009 recommendation from the National EMS Advisory Council, which determined that although there were individual EMS agencies and groups working on improving various aspects of safety, there was no overarching strategy that defined the problem or a global approach to improving it. The National Highway Traffic Safety Administration’s Office of EMS, with support from the Health Resources and Services Administration’s EMS for Children program, awarded a grant to ACEP to develop such a strategy.
ACEP sought the participation of key EMS organizations and other stakeholders. The steering committee eventually included representatives from 23 organizations, including the National EMS Management Association (NEMSMA), the National Association of State EMS Officials, the National Association of Emergency Medical Technicians , the National Volunteer Fire Council and the International Association of Fire Fighters.
“They did a good job of identifying all the people who needed to be at the table,” says steering committee member Glenn Luedtke, a paramedic for nearly 40 years and former chair of the NAEMT EMT Safety Course Committee. “We had to address dozens of different system designs, from all-volunteer to career, fire, private and third-service, and they all have their own variations. We needed to make the point that we are all in this together. Your organizational structure may be different, but there are common dangers that if you don’t pay attention to can hurt you or kill you.”
No one would suggest that anyone could make EMS 100% risk-free. EMS providers work under unpredictable circumstances, at odd hours, with limited information, assistance, supervision and resources in the field. During a shift, EMTs and medics can be exposed to risks ranging from infectious diseases to stress, fatigue and violence.
During his 36 years as a volunteer firefighter-EMT in northern Kentucky, Ken Knipper, a steering committee member and National Volunteer Fire Council Executive Committee member, had a gun pointed at him twice. During one incident, two neighbors were fighting. When he drove up, one of the people came running out of her house, yelling and waving a gun. “We never had a chance to get out of the ambulance,” he says. “We were trying to talk her into putting down the gun while we waited for police cruisers to pull up.”
Another time, a family called 911 for help with a relative having a mental health crisis. “We walked into the house and we should have known something was up because all the people who lived there were standing outside,” Knipper says. “We walked in, turned left, and he was sitting in the bathroom with a gun pointed right at us.”
Both incidents ended without injury, but they easily could have gone the other way, Knipper says. At the time, responders had no training in how to avoid those situations or handle them if they occurred. “If this document can raise awareness and save a couple of lives, then it will be very well worth it,” he says.
While workforce safety is a major concern, so are risks to patients and the public, whether it’s from unsafe driving or poor vehicle designs, medical errors or protocol lapses, notes Chris Shimer, a steering committee member and retired chief of the Howard County Department of Fire & Rescue in Columbia, Md. Though limited reporting requirements and privacy laws make determining the scope of safety issues hard to measure, one of the strengths of the Culture of Safety document is that it looks at safety for all of those potentially impacted.
“We’re not only interested in the safety of our own people—it’s also about preventing medical errors and protocol errors,” says Shimer. “It’s about all the people we touch, whether it’s the patient or the public.”
Elements of EMS safety culture
As the document took shape, six core elements that constitute an EMS culture of safety emerged. One is “Just Culture,” a non-proprietary strategy to prevent and learn from mishaps and mistakes that’s already in use by other high-stakes industries such as hospitals and airlines.
The typical way many organizations deal with mistakes is to focus on the outcome and punishment—that is, a bad outcome is punished harshly while a mistake that resulted in no harm is basically brushed aside since there were no obvious consequences. Instead of emphasizing outcomes, Just Culture focuses on the systems and behaviors that led to the mistake. It’s based on the understanding that human beings, no matter how well-intentioned, are not machines—they will, inevitably, make a mistake at some point. Instead of being punitive, organizations that practice Just Culture put systems of checks and balances in place to avoid errors as much as possible.
When errors do occur, employees are encouraged to report them, as well as near-misses, to improve processes without fear of reprisal. Instead of hiding mistakes, transparency enables the individual and the organization to learn from errors and make changes to avoid them in the future.
In the Just Culture philosophy, people are still held accountable for things like reckless behavior, but they are not punished for inadvertent errors. The emphasis is on fixing the behavior rather than assigning blame. “Just Culture is one example of a safety management program that could be used,” Murray says. “If I’m the medic who backed up without a spotter or drove too fast and I think I’m going to get punished, I’m not going to want to admit it. Fear of punishment has been proven not to be an effective [contributor to] safety.”
Other elements of a culture of safety include:
- Coordinated support and resources Advancing EMS safety industry-wide will require the support, guidance and resource-sharing from a broad spectrum of stakeholders. Establishing an EMS safety resource center could facilitate this. The resource center would not have regulatory or enforcement authority, but it could monitor progress and facilitate information-sharing. The resource center would not replace other initiatives, but would supplement and support them.
- EMS safety data system A lack of complete or centralized data to analyze the scope of EMS responder injuries, adverse medical events and adverse events involving the community hinders efforts to address these issues. An EMS safety data system, the authors wrote, would serve as a “national, robust, well-designed, secure data system linking and communicating with existing data systems to encompass key information about EMS safety.” The system would be accessible to researchers, policy-makers, stakeholder organizations and EMS agencies.
- EMS education initiatives A culture of safety must be fully integrated into each component of EMS education—not as an afterthought or chapter in a textbook.
- EMS safety standards EMS should adopt evidence-based or consensus-based standards that promote safety from an operational, technical and cultural perspective.
- Requirements for reporting and investigation Mandating reporting of important safety-related information is needed to make the national EMS safety data system effective. Steps to achieve this include determining what information is useful and what data is already available or mandated. This could include adding new data points to the National EMS Information System.
“There are pockets of data,” Murray says. “There have been small studies done on patient safety, and ambulance crash data is available from various sources at the state level and at NHTSA, but there is nothing to connect the dots. There is no organized way to collect it and compare it across the country, and to determine if a safety issue is unique to Texas, or California, or is happening in every state.”
Though EMS has certain unique attributes, it also faces similar safety issues as other professions—firefighters, hospital staff and even FedEx or UPS personnel included. Forty years ago, “America Burning,” a report written by the National Commission on Fire Prevention and Control, detailed the startling high death rate from fires among the public and firefighters and made recommendations for staunching the losses through better fire prevention and firefighter training. In the decades after the report, changes such as improved building codes and public education campaigns around fire prevention are widely considered to be one of the nation’s greatest public health successes—and have helped make firefighting a safer job than it once was.
Yet the fire service didn’t stop with the 1973 document. Concerned that there were still about 100 line-of-duty deaths annually and 10,000 serious injuries, in March 2004, the National Fallen Firefighters Foundation launched the 16 Firefighter Life Safety Initiatives, also called “Everyone Goes Home.” The initiatives included improving safety through better training, accountability, risk management, physical fitness — and, yes, cultural change.
Like EMS, the fire service also has to grapple with workforce attitudes that a high level of risk and injury are acceptable. “The concept of organizational cultural change may not come easily to many firefighters who are not only resistant to change but who may perceive it as an esoteric ‘management flavor of the month’ or an attack on fire service traditions. Most challenging for those who advocate for the safety culture change, however, is its unavoidable collision with the fire department’s heroic identity,” says a white paper describing the cultural change initiative. “Those who understand that fundamental changes in attitudes and beliefs must occur if line-of-duty deaths (and by extension, serious line-of-duty injuries) are to be reduced must answer the questions, How (or can) the fire department create a new safety culture and still be the fire department? And, Can we be safe and courageous at the same time?”
Addressing patient safety
When it comes to hospitals, what EMS has in common is, of course, patient care. In 1999, the Institute of Medicine released “To Err is Human: Building a Safer Health System,” which crystallized the problem of preventable medical errors in hospitals. The report was a landmark in patient safety literature and jumpstarted public and professional debate, according to a 2005 article describing the impact of the report by two of its authors that was published in the Journal of the American Medical Association.
“While To Err Is Human has not yet succeeded in creating comprehensive, nationwide improvements, it has made a profound impact on attitudes and organizations. First, it has changed the way health care professionals think and talk about medical errors and injury, with few left doubting that preventable medical injuries are a serious problem,” they wrote.
And the second major effect? Raising awareness and getting a wide range of stakeholders interested and committed to improving patient safety.
If the Culture of Safety document can do the same for EMS by raising awareness about safety for patients and providers alike, the project will have been a huge success, steering committee members say. “Awareness is 99% of the battle,” Luedtke says. “Folks just aren’t aware this is an inherently unsafe profession. They get hurt doing this, yet a lot of it is preventable.”
Still, there are thorny questions, including that if the reporting of errors is mandatory, what should be done with the information? Where should it be housed, and who should have access to it? There’s also the question of next steps. Some feel that subsequent efforts need to be more specific, going beyond a broad strategy and providing a toolkit that EMS agencies can use to make real-life improvements.
Although the document is strategic in nature and written for high-level leadership, it contains information that local EMS agencies will find valuable, says Skip Kirkwood, past president of NEMSMA and director of EMS in Durham County, N.C. “There will be places where it will become one of those binders that sit on the shelf and collect dust,” Kirkwood says. “On the other hand, there will be places that will take it to heart and use it as a basis for doing good stuff.”
And in providing a national framework for change, the Culture of Safety document will help to move the process along in a more coordinated, collaborative way than it would otherwise occur. “It’s going to take a lot of time to change culture, but now we have some guidance,” Knipper says.
