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Introduction of a Prehospital Critical Incident Monitoring System—Pilot Project Results

Published online by Cambridge University Press:  28 June 2012

Julian Stella ,
Anna Davis ,
Paul Jennings  and
Bruce Bartley
Julian Stella*
Affiliation:
Emergency Medicine Specialist, Geelong Hospital, Geelong, Australia
Anna Davis
Affiliation:
Senior Registrar, Geelong Hospital, Geelong, Australia
Paul Jennings
Affiliation:
Senior Operations Officer, Rural Ambulance Victoria, Victoria, Australia
Bruce Bartley
Affiliation:
Emergency Medicine Specialist, Geelong Hospital, Geelong, Australia
*
Geelong Hospital, Emergency Department Ryrie St. Geelong 3220 Victoria, Australia E-mail: julianst@barwonhealth.org.au
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Abstract

Background:

Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited.

Problem:

Implementation of an incident monitoring process in a prehospital setting.

Methods:

This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents.A project committee coded and logged all incidents and developed recommendations.

Results:

Of 4,429 ambulance responses, 41 cases were analyzed.Twenty-four (58.5%; 95% CI = 49.7–67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03–2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98–1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91–8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04–2.16). A total of 56 of 77 (72.7%; CI = 65.5–80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7–68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4–50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3–49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6–91.3%); in three cases (3.9%; CI = 3.7–4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5–2.7%); three cases resulted in remedial action (3.9%; CI = 3.7–4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9–5.5%).

Conclusions:

The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types.The large proportion of incidents in the “near miss” category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.

Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 23 , Issue 2 , April 2008 , pp. 154 - 160
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2008

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References

1. Runciman, WB, Sellen, A, Webb, RK, et al. :The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993;21(5):506–519.CrossRefGoogle ScholarPubMed
2. 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.Google ScholarPubMed
3. Leape, LL: Reporting of adverse events. N Engl J Med 2002;347(20):1633–1638.CrossRefGoogle ScholarPubMed
4. 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
5. 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
6. 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
7. Runciman, WB, Edmonds, MJ, Pradhan, M: Setting priorities for patient safety. Qual Saf Health Care 2002;11(3):224–229.CrossRefGoogle ScholarPubMed
8. Spigelman, AD, Swan, J: Review of the Australian incident monitoring system. ANZ J Surg 2005;75(8):657–661.CrossRefGoogle ScholarPubMed
9. Hart, GK, Baldwin, I, Gutteridge, G, Ford, J: Adverse incident reporting in intensive care. Anaesth Intensive Care 1994;22(5):556–561.CrossRefGoogle ScholarPubMed
10. 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
11. Vinen, J: Incident monitoring in emergency departments: An Australian model. Acad Emerg Med 2000;7(11):1290–1297.CrossRefGoogle ScholarPubMed
12. 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
13. 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
14. 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; 1994, 31 March 1994.Google Scholar
15. 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; 1995, 31 March 1995.Google Scholar
16. 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
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; 2003, 31 December 2003.Google Scholar
18. 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
19. 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
20. 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
21. 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
22. Boyle, M, Archer, F, Macdonald, R: Incident Monitoring: A Review of the Literature and Development of a Pre-Hospital Model. Melbourne: Monash University; 2002.Google Scholar
23. 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
24. 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
25. 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
26. Lawton, R, Parker, D: Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002;11(1):15–18.CrossRefGoogle ScholarPubMed
27. Landrigan, CP, Rothschild, JM, Cronin, JW, et al. : Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351(18):1838–1848.CrossRefGoogle ScholarPubMed
28. 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
29. Brennan, TA, Gawande, A, Thomas, E, Studdert, D: Accidental deaths, saved lives, and improved quality. N Engl J Med 2005;353(13):1405–1409.CrossRefGoogle ScholarPubMed
30. 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
31. Thomas, EJ, Lipsitz, SR, Studdert, DM, Brennan, TA: The reliability of medical record review for estimating adverse event rates. Ann Intern Med 2002;136(11):812–816.CrossRefGoogle ScholarPubMed
32. Reason, J: Human error: Models and management. West J Med 2000;172(6): 393–396.CrossRefGoogle ScholarPubMed
33. Leonard, M, Graham, S, Bonacum, D: The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13 Suppl 1:185–90.CrossRefGoogle ScholarPubMed
34. Kluger, MT, Bullock, MF: Recovery room incidents: A review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;57(11):1060–1066.CrossRefGoogle ScholarPubMed