Culture of Safety for Paramedics

EDWARD R. MYERS

Mar 15, 2012

The Strategy for a National EMS Culture of Safety asserts that "Emergency medical service (EMS) provider organizations nationwide potentially expose patients, practitioners and members of the public to preventable risk of serious harm, in contrast with advances in safety practices that have been broadly implemented in many other healthcare settings in recent years."

This sounds like a very "bad news" story from the EMS providers in the United States. In fact, although their "news" may sound bad, the fact is that this group is talking about turning a "culture of risk" in the EMS industry into a "culture of safety".

This project is being produced under a cooperative agreement between EMS stakeholders in the U.S. - including the National Highway Traffic Safety Administration (NHTSA), with support from the Health Resources and Services Administration's EMS for Children (EMSC) Program, and is being managed by the American College of Emergency Physicians (ACEP).

In establishing the need to come to grips with the enduring requirement for EMS operations to perform at maximum peak, the working group generalized that, "the sphere in which EMS operates is complex and frequently changing, and its mission is complicated by emotionally charged situations and public expectations that are not always reasonable or realistic".

Facing Risk and Danger
As with the other two tri-service organizations, law enforcement and firefighting, there is an "A-type" personality element to the EMS profession. As stated in the strategy document, many EMS recruits "are drawn to the perceived adventures that accompany a career that involves lights and sirens, driving fast and working in life-and-death situations." The fact is, we would not feel comfortable with EMS personalities of the opposite type if our family's lives were in danger and required decisive and immediate response.

What can Canada Learn from the U.S. EMS Experience?
Many issues that gave rise to the development of a National EMS Culture of Safety Strategy in the U.S. are equally relevant to Canada. Primarily, the idea of a "culture" of safety is important, as it underpins the whole need for a comprehensive examination of the way EMS services operate.

Culture implies a deep-rooted commitment to a cause and the three pillars of EMS safety - patient, responder, and public safety. The U.S. has borrowed the following definition that should work equally well in Canada - or just about anywhere else in the world for that matter:

Safety culture:
"The enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety; act to preserve, enhance and communicate safety concerns; strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes; and be rewarded in a manner consistent with these values." (Douglas A. Wiegmann, Hui Zhang, Terry von Thaden, Gungan Sharma and Alyssa Mitchell)

To get there, a number of challenges must be addressed, some of which require wholesale changes in structure and/or behaviour. In each case, the Canadian approach could mirror that of the U.S. in terms of openness to change and willingness to fundamentally re-evaluate attitudes and more tangible items like infrastructure and funding commitments. Stemming from the Strategy draft, the following checklist of critically important aspects of change could frame a new culture of safety for EMS in Canada:

Resource Limitations. EMS constantly finds itself vying for budget and other municipal resources as it is asked to expand capability with diminishing money. Perhaps the most troublesome aspect of this resource squeeze is the distraction it causes at both an organizational and a leadership level.

Lack of a Systems Approach. EMS organizations respond to events and are very good at that. Other public safety sectors - aviation safety to name one - have adopted a systems approach to safety which has proved effective over time.

Personality Types. As described earlier, EMS attracts 'Type A' personalities. The question becomes how to attract equally effective responders without the risk of recklessness.

Adapted Practices & Equipment. EMS culture is built on a history of adapting practices, vehicles and equipment originally developed for other applications in medical or emergency response fields. According to the draft EMS Culture of Safety Strategy, some equipment and protocols have been designed exclusively for EMS field use but, historically, the culture has not demanded its own set of tools, and, consequently, is not particularly adept at articulating specific requirements for the job.

Operational Performance Pressures. For most EMS personnel, on-the-job pressure is very high, not necessarily due to the high energy activity of the job, but due to the need to achieve response times that are contractually set or set by management. Moreover, increased performance becomes a management mantra that ends up subjugating safety for performance.

Disasters. When disasters strike, the rulebook sometimes goes out the window. This can be true for EMS personnel as well if the scope of the disaster goes beyond the normal operating environment.

Misplaced Beliefs. Ironically, one of the elements seen out as problematic is "the widespread cultural belief in 'going all out' for patients, which can lead to poor safety choices and unsafe actions (such as driving unsafely, rushing procedures, taking shortcuts, failing to use personal protective equipment, etc.)".

Influence of Media Depictions. Media portrayals of EMS personnel in action dramatize the elements of response time (the need for speed, and risky driving behaviour). While it may be depicted in movies as heroic behaviour, the truth is, it is more likely negligent or careless at best. As the Strategy notes, such action movies can unwittingly attract risk-taking personalities to the EMS field.

Patient Safety Misperceptions. The Strategy draft states that "many EMS personnel do not fully understand the concept of patient safety, particularly when it comes to medical errors or harm that results from errors of commission or omission. Typically, they think of patient safety as protecting the patient from injury resulting from drops or crashes."

Gaps in Leadership Development. As in other emergency management disciplines, or other healthcare business environments for that matter, there are proven methods and procedures for assessing, selecting and developing leadership skills that can be brought to the EMS arena. These need to be adapted and adopted in a manner consistent with the overall development of a culture of safety.

Disconnect Between Clinicians and Leadership. In the U.S., there is concern that some EMS systems are led by administrators who have no clinical experience. While this seems to be less prevalent in Canada, it is a situation that requires examination.

Cynicism/Mistrust of Leadership. While not an exclusive concern to the EMS community, the U.S. experience has seen a "common (although not universal)" situation where EMS personnel mistrust their leadership, even if for unknown reasons.

"Check the Box" Safety. Evidence from the U.S. experience shows the EMS culture pays lip service to safety considerations.

Additionally, this veritable disdain for safety is likely to be reinforced in trainees by experienced EMTs and paramedics.

Focus on Response Times. Oddly, the use of response times as a metric for EMS effectiveness has been shown to be inaccurate.

According to the document, there is "scant evidence that the difference between a lights-and-siren response and a non-emergency response makes a clinical difference."

Reinforcement of Unsafe Behaviour. The Strategy document claims the "system" has perpetuated a myth that the individual is to blame when things go wrong, whereas the fault actually lies with the lack of a culture of safety and a system to support it.

Lack of National Priority. The draft document concludes that a Culture of Safety is indeed becoming a national priority in the USA. It is hoped that Canadians will similarly place a higher priority on safety.

Prescription for a Canadian EMS Culture of Safety
With these cautions in mind, what is the way forward? To achieve a true Culture of Safety, the Strategy recommends focusing on some fundamental changes that will ultimately realize an improved safety environment for patients, responders, and the public. These developments will undoubtedly be effective in Canada as well, and should serve to support cross-border harmonization, should the need arise in the future.

Increase efforts to develop new data and quality measurement systems.
Create an environment of empowerment where everyone in the EMS world - from trainer to trainee to responder and management - embraces the concept of a Culture of Safety and feels personally empowered to act in the interests of safety at all times.
Develop an environment of knowledge whereby all relevant personnel, from the top of the organization to the newest recruit, constantly strive to know what it takes to maximize patient, responder, and public safety.
Foster an environment of openness where, rather than getting swept under the rug, mistakes are corrected and used as teaching points.
Promote an environment of inclusiveness throughout the organization, including intra-jurisdictionally, so that all components of a Safety System feel engaged and involved.
Create an environment of continuous improvement, with the understanding that fundamental shifts like this require time and diligence.