The Center for Leadership, Innovation and Research in EMS (CLIR), along with its sponsoring organizations – the EMS Chiefs of Canada, the National EMS Management Association and the North Central EMS Institute – announced a new patient safety initiative. The EMS Voluntary Event Notification Tool (EVENT) provides an anonymous tool for EMS providers and others to report adverse events that occur in the EMS setting. CLIR is a non-regulatory, not-for-profit group that is promoting and advancing the practice and profession of EMS internationally. The National Association of State EMS Officials is a partner organization for EVENT and CLIR will begin seeking additional partner organizations this month.
The goal of every emergency medical provider (first responder, E.M.T., Paramedic, Flight Nurse, Physician and others) is to respond to patients in their time of need and to provide them with the most appropriate and highest quality care possible. This care is frequently critical to a patient’s health or survival and is often provided in settings that are challenging, chaotic and even hazardous. Decisions and actions by emergency medical providers are sometimes influenced by environmental factors but are always based upon the experience, training, protocols, medical direction, common medical practice and ultimately the provider’s best judgment. Regardless of training, experience and especially the intent of the provider, medical errors in the EMS setting occur and cause harm or even take the life of the very patients the system is intending to save.
Emergency Medical Services (EMS) are an important part of the healthcare system and have the responsibility to do no harm. It would be naive to think that errors in EMS either don’t exist or that nothing can be done to reduce or even eliminate them. One tool that moves systems in this direction is an “Event Reporting System.” An Event Reporting System allows providers to anonymously report safety events that have occurred, could have occurred or could potentially occur in order to capture the event so work can be done to improve the system of care.
Anonymous reporting models have been in place for industries such as aviation for decades. The model for EVENT was first developed and used by the state EMS office Pennsylvania. The purpose of the Pennsylvania system and that of EVENT is to collect and utilize valuable information from anonymous reports to help improve the consistency and quality of the care in the EMS arena. Information provided in these anonymous reports identify needed changes in the systems and processes without placing blame on the individual provider. The EVENT system is not designed to nor can it directly improve either the quality or consistency of care provided by EMS systems. EVENT is a channel for thoughtful, accurate and timely notification through anonymous submissions to the appropriate state, territory or provincial EMS governing body. Once the governing body receives the anonymous notification, they are encouraged to address systemic issues in order to improve the overall quality of care provided.
The EVENT system can be used to anonymously report any patient-safety related issue such as:
- “Sentinel Events” where unexpected or unintended occurrences result in serious physical injury, psychological trauma or death
- Unexpected or unintended occurrences that result in any physical injury or psychological injury of a patient, including adverse drug reactions
- “Near Misses” which are close calls that could have resulted in accident, injury or illness but did not either by chance or through timely intervention
- Equipment or device failures, malfunctions or provider errors of omission (not using when called for) or misuse (using it in the incorrect way); that cause or could cause harm to a patient.
- Lessons learned, safety ideas and/or concerns or any topic that has been vetted through local authority either without resolution or the reporting person feels that it cannot be brought up with local authority without the risk of repercussion
The EVENT system is only applicable to patient safety events that are related to care given by components of the pre-hospital or out-of-hospital EMS system including but not limited to: ambulance attendants, first responders, all levels of EMTs and paramedics, Critical Care Transport service personnel, quick response services, ambulance services, air ambulance services, dispatch centers and medical command facilities. EMS agencies that operate their own internal event reporting system are encouraged to also report their events anonymously through EVENT.
EVENT is one effort of many to improve the safety and quality of care provided by EMS. Thank you for your interest in improving EMS. Please help spread the word about the availability of EVENT throughout the EMS community in the US and Canada.