Disclosure of Harmful Medical Errors in Out-of-Hospital Care

Uncomfortable yet necessary: The impact of PPE on communication in emergency medicine

BACKGROUND

The efficacy of pre-hospital emergency services is heavily dependent on the effective communication of care providers. This effective communication occurs between providers as part of a team and also among providers interacting with family members and patients. The COVID-19 pandemic introduced a number of communication challenges to emergency care, which are primarily linked to the increased use of personal protective equipment (PPE).

OBJECTIVE

We sought to analyze the impacts of the COVID-19 pandemic on emergency medical service (EMS) workers and pre-hospital care delivery.

METHODS

We conducted focus groups and one-on-one interviews with fire-based EMS first responders between September 2021 and 2022. Interviews included questions about job-related stress, EMS skills, work experiences and changes during COVID-19. Interviews were recorded, independently dual coded and analyzed for themes.

RESULTS

Two hundred twenty-three first responders participated in 40 focus groups and 40 lead paramedics participated in individual interviews. We found that additional use of PPE was reported to have significantly impaired efficiency and perceptions of quality of care-among EMS team members and also between EMS workers and patients. EMS personnels also experienced on-scene hostility on arrival (from both families and other agencies). Extensive use of PPE muffles voices, obscures facial expressions and can cause team members to have difficulty recognizing and communicating with one another and can be a barrier to showing empathy and connecting with patients. Creative solutions such as putting a hand on someone's shoulder, wearing name tags on suits and explaining rationale for perceived delays were mentioned as methods to transcend these barriers. The appearance of providers in heavy PPE can be unsettling and create barriers to human connection, particularly for pediatric patients.

CONCLUSION

Human connection is an important element of health-care delivery and healing. These findings shed light on new skills that are needed to initiate and maintain human connection in these times of PPE use, especially full-body PPE. Awareness of the communication and empathy barriers posed by PPE is the first step to improving provider-patient interactions in pre-hospital EMS. Additionally, 'communication-friendly' adaptations of PPE equipment may be an important area for future research and development in manufacturing and the health-care industry.

Relationship between the depressive state of emergency life-saving technicians and near-misses

Aim

A depressive state is a key risk factor for medical errors made by emergency life-saving technicians (ELSTs). However, no study has examined the occurrence of near-misses in ELSTs. We investigated the association between a depressive state and near-misses among ELSTs.

Methods

A cross-sectional study was undertaken in 345 ELSTs using an anonymous self-administered questionnaire. The main exposure was a depressive state that was measured using the Quick Inventory of Depressive Symptomatology. For the main outcome, near-miss events, we calculated odds ratios (OR) of depressive states, adjusted for age and work-related factors by multivariable logistic regression. For exploratory purposes, we also undertook secondary analyses to determine whether work-related factors were associated with a depressive state.

Results

We obtained 254 responses. Compared to ELSTs without a depressive state, the adjusted OR for near-misses among ELSTs with a mild depressive state was 3.14 (95% confidence interval [CI], 1.37-7.16; P = 0.007), and that among ELSTs with a moderate or greater depressive state was 5.29 (95% CI, 1.46-19.09; P = 0.011). For a depressive state, in the exploratory analyses, the OR of nap duration while on duty for less than 2 h was 3.34 (95% CI, 1.15-9.67; P = 0.027), that for irregular mealtime while on duty was 3.71 (95% CI, 2.00-6.86; P < 0.001), and that for a duration of desk work of 4 h or longer was 2.21 (95% CI, 1.15-4.25; P = 0.017).

Conclusion

A depressive state was significantly associated with the occurrence of near-misses among ELSTs. That a depressive state among ELSTs was related to nap duration and excessive office work indicates that improved management of the work environment and operations of ELSTs is necessary for the provision of safe emergency medical services.

The role of the emergency medical dispatch centre (EMDC) and prehospital emergency care safety: results from an incident report (IR) system

Introduction

The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives.

Methods

An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010.

Results

During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population.

Conclusions

Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a “learning organization” and improve both efficacy and safety of first aid care.

Physician assistants and the disclosure of medical error

Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

A case of error disclosure: a communication privacy management analysis

To better understand the process of disclosing medical errors to patients, this research offers a case analysis using Petronios’s theoretical frame of Communication Privacy Management (CPM). Given the resistance clinicians often feel about error disclosure, insights into the way choices are made by the clinicians in telling patients about the mistake has the potential to address reasons for resistance. Applying the evidenced-based CPM theory, developed over the last 35 years and dedicated to studying disclosure phenomenon, to disclosing medical mistakes potentially has the ability to reshape thinking about the error disclosure process. Using a composite case representing a surgical mistake, analysis based on CPM theory is offered to gain insights into conversational routines and disclosure management choices of revealing a medical error. The results of this analysis show that an underlying assumption of health information ownership by the patient and family can be at odds with the way the clinician tends to control disclosure about the error. In addition, the case analysis illustrates that there are embedded patterns of disclosure that emerge out of conversations the clinician has with the patient and the patient’s family members. These patterns unfold privacy management decisions on the part of the clinician that impact how the patient is told about the error and the way that patients interpret the meaning of the disclosure. These findings suggest the need for a better understanding of how patients manage their private health information in relationship to their expectations for the way they see the clinician caring for or controlling their health information about errors.