Professional groups, including paramedics, adopt specific values, moral obligations or responsibilities that go beyond the basic duties of the public. In Epidemics, Book 1, Section 11 Hippocrates notes: ‘As to diseases, make a habit of two things—help or at least to do no harm.’ Such sentiment applies to paramedics today as it was applied to the medicine men of yesteryear. Patient safety is a serious global public health issue. Estimates demonstrate that in developed countries as many as one in 10 patients are harmed while receiving hospital care (World Health Organization (WHO), 2016).
The patient first and foremost
Protecting the public and enhancing patient safety is the first concern of the paramedic (Health and Care Professions Council, 2016). Patient safety is a challenge globally and requires knowledge and skills in a number of areas, including human factors and systems, as it does not occur in isolation. The provision of healthcare work and those systems and processes associated with it are complex. There is a growing need for even closer partnerships between the health sciences, human factors and systems required to improve patient safety.
Over the years the provision of pre-hospital care has noticeably changed. The discipline has developed and combines medicine, public health and public safety, and the provision of medical care delivered by professionally qualified practitioners. Developments have been built on a robust evidence base demonstrating the ability and competence to enhance patient outcomes through the appropriate application of clinical interventions (Australian College of Ambulance Professionals, 2011).
The quality and efficacy of patient outcomes is often conditional upon the quality of initial care provided. As such, the quality and safety of early interventions can have a decisive impact on subsequent patient outcomes.
Patient safety
On a daily basis patients are placed at risk of harm within all aspects of the healthcare system. These risks are particularly evident in the delivery of pre-hospital care, where paramedics treat patients under sometimes hostile working conditions, and often this is without any patient history. Clinical judgements have to be made in the field that can have a significant impact on patient outcomes; the interventions undertaken by the paramedic can pose substantial risks. Pre-hospital emergency medicine involves offering immediate medical care in what is frequently a resource limited and physically challenging setting (Intercollegiate Board for Training in Pre-hospital Emergency Medicine, 2012).
As a result of caring for patients in challenging and dynamic environments, those providing pre-hospital care (paramedics) may contribute to an increased risk for adverse events (Bigham et al, 2012). These conditions provide the perfect storm for errors to be made and for harm to be caused. Paramedics offer care to people that is underpinned by the fundamental principles of medical ethics, whereby the paramedic must first do no harm—primum non nocere. Harm may include disease transmission, increased lengths of stay in hospital, intentional or accidental injury, suffering, disability and even death (WHO, 2011; Batt, 2016).
Hospital mortality is seen as a key indicator of patient safety (Donaldson et al, 2014), yet methodologies for assessing mortality in the pre-hospital setting need refinement as they seldom point directly to areas of risk and solutions. Little is known about the risks to patient safety in the pre-hospital setting. Bigham et al (2012), in discussing patient safety in Canadian pre hospital settings, note that pre-hospital emergency care is an area representing high risk for errors and harm, but it has received rather little consideration in the patient safety literature.
Reducing harm
In attempting to reduce harm in the pre-hospital setting, a key aspect is to identify the threats to patient safety that are unique to this setting, and in this area more research is needed. Interventions that mitigate against threats to safety need to be identified.
Risks to safety can be categorised into a number of themes, and medication errors are but one theme. Medication error is seen as a significant concern within healthcare practice and there is no reason to suggest that paramedic practice is immune to this disturbing problem. Being able to carry out drug calculations correctly is essential to patient safety.
Hubble et al (2000) and Eastwood et al (2009) have determined that there is some level of mathematical deficiency noted among paramedics: the longer the paramedic has been qualified, the greater medication errors noted. In stressful simulated scenarios, LeBlanc et al (2005) observed paramedics scoring lower medication calculation accuracy. Acknowledging that the work of the paramedic is often stressful, stress can have a negative impact on the practitioner's health and well-being and the propensity to make drug calculation and administration errors will increase.
The identification and the monitoring of clinical incidents in the pre-hospital setting is not as fully developed as it might be (Jennings and Stella, 2011), and this should be given further consideration in mitigating harm, adverse events and near miss events. The outcomes from these events and the investigations that ensue can be used to inform changes in clinical practice and organisational practices as well as informing educational programmes with the aim of enhancing patient safety.
Education
The explicit inclusion in pre-registration and post-registration (CPD) curricula concerning the relationship between error and the harm this can cause and the improvement of patient safety is essential. When patient safety issues occur it is unusual for a single event to be wholly responsible. It is more likely that a series of errors (and these may be minor) happen consecutively or concurrently causing the Swiss cheese effect, where the holes line up and a serious event occurs. An understanding of the human factors, human behaviour and human imperfection in the design of safe systems can take its toll on patient and paramedic safety. There is a need to give further consideration to technology and its place in reducing errors or conversely the role it can play in creating new errors.
Effective teamwork and effective communication already feature in various curricula. The use of effective handover protocols from the ambulance to the emergency department have been found to be inconsistent and incomplete, bringing with it major implications for patient safety and survival (Idema et al, 2012). Other tools used for safe and effective communication such as SBAR (situation, background, assessment, recommendation/recap) is underutilised (in pre-hospital and hospital care). This may help to provide a smoother transition of information improving the ambulance/emergency department interface.
The NHS on a daily basis treats millions of people safely and with success. When incidents do occur, however, it is important that we learn from adverse events. Implementing root cause analysis is a well recognised way of doing this (National Patient Safety Agency, 2011).
Root cause refers to the essence or fundamental issue; it is the earliest point at which action could have been taken that would have reduced the chance of the incident happening. This is a structured process that uses recognised analytical methods, enabling the paramedic to ask the questions ‘How?’ and ‘Why?’ in an objective manner, with the intention of revealing all the causal factors that led to a patient safety incident. Using this approach, analysing a critical incident and implementing system changes can help to prevent similar incidents occurring again. The aim is to enhance self-reporting and not to feed a blame culture but to generate a culture of safety in the work place. When this is successful, paramedics and managers can speak up about safety concerns, mistakes and errors (Frey and Schwappach, 2010).
Conclusions
Doing no harm is the prime concern of every paramedic locally, nationally and internationally yet each year millions of people worldwide are harmed by care provided. The healthcare context is highly complex and, for the paramedic, care is often delivered in pressurised and fast-moving environments that can involve technology with paramedics making individual decisions and judgements. In these circumstances things can and do go wrong, there are times when unintentional harm comes to a patient during a clinical procedure or as a result of a clinical decision.
Ways of reducing harm will include implementing ways of mitigating against threats to safety. Education is a key way of understanding the relationship between error and harm, as is learning from mistakes using a structured analytical tool such as root cause analysis.