Introduction
Improving individual and patient safety for prehospital Emergency Medical Services (EMS) systems is widely recognized as a core component of an effective EMS system. Many authors conclude that EMS safety data surrounding untoward events is not comprehensively reported due to barriers such as organizational culture,Reference Kaplan and Fastman 1 a focus on blaming the individual rather than evaluating system problems,Reference Barach and Small 2 , Reference Bigham, Bull and Morrison 3 and reluctance to admit errors based upon fear of consequences (i.e., a culture of fear).Reference Bion, Abrusci and Hibbert 4
Patient safety in health care has recently focused on mishap reduction by adapting reporting systems from other, non-medical industries,Reference Barach and Small 2 standardizing systems for evaluation of near-miss events, and changing the focus from blaming the individual to addressing system problems through the coordinated efforts of multidisciplinary teams. 5 One of these approaches to error reduction is Human Factors Analysis (HFA), which is proven in non-medical industries (aviation, nuclear power, military) and can be applied to the safety of both patients and prehospital care providers. HFA supports non-punitive reporting of errors, and focuses on a systems approach to error reduction which helps foster a “just culture” that is characteristic of high-reliability organizations.
This report is of an incident in which EMS first responders became exposed to Carbon Monoxide (CO) while on the scene of a call, with HFA used to outline proposed error reduction mechanisms for the event.
Incident Overview
EMS crews were dispatched to a commercial food supplier warehouse for a 70 year-old male who had collapsed. The first arriving paramedic unit discovered a 70 year-old male lying near a forklift, unconscious and unresponsive, although breathing. The paramedic unit crew's attention was focused on this critically ill patient and the initiation of airway and respiratory support.
A first-responder fire engine arrived on scene shortly after the ambulance. The Captain of the engine crew became aware of an alarm coming from a “gas badge” or atmospheric gas monitor (Gas Badge Plus Single Gas Monitor, Industrial Scientific Corporation, Oakdale, Pennsylvania USA), with the gas badge reading “Over Range.” (As part of an ongoing department-wide safety program, a “gas badge” had been affixed to the oxygen bag of each ambulance.) At this time, the paramedic unit crew was beginning to move the patient to the ambulance. Once in the ambulance, the patient was intubated, and evaluated with the RAD-57 CO monitor (Masimo Corporation, Irvine, California USA). Initial CO levels measured were 48%, despite ventilation with 100% oxygen for approximately 10 to 15 minutes. Following identification of CO as a likely cause for the patient's unconsciousness, he was transported to a hyperbaric chamber specialty center. On arrival, his initial arterial blood gas included an oxygen saturation of 61%, and an arterial carboxyhemoglobin level >30%. The patient underwent a 90-minute “dive” session, following which the carboxyhemoglobin level decreased to 1.9% within an hour. He was successfully weaned from the ventilator, and discharged with no neurologic deficits.
The engine crew recognized this Immediately Dangerous to Life or Health (IDLH) atmosphere environment, evacuated all workers and donned self-contained breathing apparatus (SCBA). The building was treated as a HAZMAT (hazardous materials) scene, and safety personnel entered the structure to ensure all workers were evacuated. Crews utilized the ITX Multi-Gas (Industrial Scientific Corporation, Oakdale, Pennsylvania, USA) monitor to assess the environment, and measured CO readings in excess of 1500 ppm (parts per million). The United States National Institute of Occupational Safety and Health states that the IDLH level for inhaled Carbon Monoxide is 1200 ppm. 6 It was determined that the area the patient was found in was an industrial refrigerator in which a propane powered forklift was being operated. This forklift had been left running, resulting in the generation of CO gas. The refrigerator's near-airtight environment prevented dissipation of the CO gas, and nearly three hours of active ventilation were required to reduce the atmospheric levels to a residual CO reading of 15 ppm.
Following evacuation of workers, the coworker who discovered the patient after collapse, and had stayed with the patient in the refrigerator for approximately 10 minutes until the ambulance arrived, complained of nausea and dizziness. The patient evaluation revealed a Glasgow Coma Score of 15, pulse 104, blood pressure 148/96, and respiratory rate of 24 with an initial O2 saturation of 97%. The initial CO reading (RAD-57) was 25%, and the coworker was treated with oxygen via non-rebreather mask and transported to the hyperbaric center with an arrival CO reading of 15%. The coworker remained stable, and was discharged without neurological deficits.
Human Factors Analysis
Carbon monoxide remains the leading cause of accidental poisoning deaths in the United States. Each year, over 500 fatalities, 20,000 Emergency Department visits and 4,000 hospital admissions are attributed to CO poisoning. 7 The colorless and odorless characteristics of CO often hinder its early recognition. Unless suspected, CO poisoning can be difficult to diagnose because the symptoms mimic other illnesses. A delay in diagnosis could have occurred in the above case, as the paramedic unit evaluated the patient for common causes of unconsciousness such as hypoglycemia, dysrhythmia, or drug overdose. However, the presence of an alarming passive gas monitoring system allowed the providers to identify the unsafe scene.
Review of this “near miss” case prompted a Human Factors Analysis (HFA). Traditional quality improvement addresses errors by attributing them to the person committing them. Using this approach creates a culture of fear in which reporting of errors is discouraged. An improved approach to both patient and provider safety is provided by using HFA to identify the root causes of flawed processes, and improve the process so that workers in future situations deliver safer performance through improved processes. HFA has been adopted in health care (Reason 2000) and by the International Association of Fire Fighters (IAFF) in partnership with the International Association of Fire Chiefs (IAFC). 8 This approach focuses on processes and systems, recognizing that providers are at the “sharp end” (in direct patient contact),Reference Reason 9 and are prone to errors through the very nature of their work.
To summarize the HFA, a paramedic and an Emergency Medical Technician (EMT)-Basic were dispatched to a high priority situation (an unconscious person) for an unconscious subject. They arrived to find the patient unconscious, but breathing, in a walk-in cooler behind a propane-powered forklift. Aware that the patient was critically ill, they rushed into the cooler to assess and begin treatment. The first active error was failing to see the potential that the scene was unsafe. Initial training at both EMT-Basic and paramedic levels stresses scene safety prior to patient assessment. Despite training and experience, these providers had not encountered this particular presentation previously. A portable toxic gas surveillance system was in place, but the alarm was not heard by the ambulance crew due in part to the high-noise environment. However, when the engine crew entered, the captain of the crew heard and investigated the alarm. It is likely that the ambulance crew compartmentalized their focus solely on the critically ill patient, excluding other sensory inputs. One description of a process causing harm is that of a chain composed of many links. Breaking a single link can prevent a bad outcome. In this case, crew resource management allowed the engine officer to pick up the auditory cue that the ambulance providers missed, clear the unsafe scene of workers and firefighters, and institute HAZMAT operations until the scene could be made safe.
In HFA, latent factors are also analyzed. There were up-to-date policies that addressed the hazard in general terms. Despite the policies, recognition of this low-frequency, high-risk situation required more training.
Conclusion
This report describes a relatively new approach to safety in both health care and prehospital emergency care. The goal of this approach, Human Factors Analysis (HFA), is to focus upon and thoroughly analyze processes for the purposes of making the environment safer for patients and providers.
Abbreviations
- CO:
-
carbon monoxide
- EMS:
-
Emergency Medical Services
- HFA:
-
Human Factors Analysis
- IDLH:
-
Immediately Dangerous to Life or Health
- ppm:
-
parts per million
- SCBA:
-
self-contained breathing apparatus
