Original contributionThe ten-year malpractice experience of a large urban EMS system
Malpractice is a recognized and growing problem for physicians and hospitals, but it is difficult to ascertain the risk of malpractice in the prehospital arena. Dade County, Florida (greater Miami), with a population of 1.7 million, currently is served by 339 certified paramedics. During the decade of 1972 to 1982, Dade County Fire Rescue handled 265,060 incidents; 16 claims were filed with the Risk Management Division of Dade County. The claims were produced by 11 incidents, which yields a rate of one per 24,096 incidents. The two greatest problems identified were inadequate record keeping and “gray zone” patients who do not fit any particular protocol.
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Cited by (51)
Tort Claims and Adverse Events in Emergency Medical Services
2008, Annals of Emergency MedicineCitation Excerpt :Our findings suggest that EMS quality improvement efforts must encompass not just clinical but also operational aspects of care. Previous efforts describing tort claims against EMS are limited to small series involving single EMS agencies.37-39 One broader effort used a public jury verdict database that included only incidents proceeding to trial, thus underestimating the frequency of adverse events.40
Emergency medical services (EMS) provide care to acutely ill or injured patients in settings less controlled than other health care environments. Although reports describing individual EMS adverse events exist, few broader descriptions exist. The objective of the study is to characterize the types, frequencies, and outcomes of adverse events associated with insurance tort claims against EMS providers.
We performed a retrospective review of insurance liability claims from a national insurer of EMS agencies. We studied closed and open insurance liability claims from January 1, 2003, to December 31, 2004, arising from EMS response to or provision of patient care and associated with injury to patients or other individuals. We excluded events associated with employee injuries only, events with property or vehicle damage only, and emergency vehicle crashes with less than $10,000 in actual or predicted total incurred costs. We identified the category of the adverse event, the characteristics of the treating emergency units, the injured individuals, the associated injuries, and the estimated or actual total incurred costs.
Among 326 claims included in the analysis, adverse events included emergency vehicle crash or movement (n=122; 37%; 95% confidence interval [CI] 32% to 43%), patient handling (n=118; 36%; 95% CI 31% to 41%), clinical management (n=40; 12%; 95% CI 9% to 16%), response or transport events (n=25, 8%; 95% CI 5% to 11%), and other events (n=33; 10%; 95% CI 7% to 14%). Associated injuries included death (n=54; 17%; 95% CI 13% to 21%), life-threatening or disabling injuries (n=25; 8%, 95% CI 5% to 11%), and non–life-threatening or other injuries (n=247; 76%; 95% CI 71% to 80%). The median estimated total incurred cost was $17,000 (interquartile range $7,000 to $42,000).
Emergency vehicle crashes and patient handling mishaps were the most common adverse events associated with tort claims against EMS agencies. Clinical management and other incidents were less common. This effort highlights potential areas for improving EMS operations and care.
Complaints against an EMS system
2003, Journal of Emergency MedicineComplaints against Emergency Medical Services (EMS) agencies represent a concerning and potentially time-consuming problem for all involved in the delivery of prehospital emergency medical care. The objective of this study was to identify the source of complaints against an EMS system to help focus quality and performance improvement and customer service efforts. We conducted a retrospective review of complaints filed against a busy urban EMS agency over a 6-year period. All complaints were included, totaled by season and by year, and categorized by originator and nature of the complaint. A total of 286 complaints were registered during the 6-year period, with an average of 48 per year and 9.3 per 10,000 responses. The most common originators of complaints were patients (53%) followed by medical personnel (19%) and family members or friends (12%). Rude behavior accounted for 23% of the complaints registered, followed by technical skills (20%), transport problems (18%), and loss of belongings (13%). The identification of areas of dissatisfaction will allow focused quality and performance improvement programs directed at customer service and risk management.
Can paramedics accurately identify patients who do not require emergency department care?
2002, Prehospital Emergency CareObjective. To determine whether paramedics can identify patients contacting 9-1-1 who do not require emergency department (ED) care. Methods. The setting was an urban county with a two-tiered, dual response to 9-1-1 calls comprising eight local fire departments with advanced life support capabilities and a private advanced life support 9-1-1 agency with primary transport responsibilities (approximately 39,000 of the 78,000 total system patient transports in this county per year). The study population consisted of consecutive patients transported by a private transporting paramedic agency. After patient contact and stabilization, paramedics completed a survey detailing the necessity for transport to an ED for each patient. Prior to data analysis, it was determined that patients would be designated as requiring ED care if they 1) were admitted, 2) required surgical, surgical subspecialty, obstetric, or gynecologic consult, or 3) required advanced radiologic procedures (excluding plain films). Sensitivity, specificity, and predictive values for paramedic assessment of necessity for ED care were calculated with 95% confidence intervals (95% CIs). Results. Over the study period, 313 patients were enrolled. Paramedic assessment was 81% sensitive (72-88%, 95% CI) and 34% specific (28-41%, 95% CI) in predicting requirement for ED care. In 85 cases where paramedics felt ED transport was unnecessary, 27 (32%) met criteria for ED treatment, including 15 (18%) who were admitted and five (6%) who were admitted to an intensive care unit. Conclusion. In this urban system, paramedics cannot reliably predict which patients do and do not require ED care. PREHOSPITAL EMERGENCY CARE 2002;6:387-390
The effect of a quality improvement feedback loop on paramedic-initiated nontransport of elderly patients
2002, Prehospital Emergency CareObjective. To examine the effect of a paramedic educational program and quality improvement feedback loop on paramedic-initiated nontransport of patients 65 years of age and older. Methods. Prospective observational study. Patients 65 years of age and older who were evaluated but not transported by paramedics were contacted by telephone within two weeks of emergency medical services (EMS) contact and asked: 1) whether the patient sought medical help within 24 hours after contact; 2) whether the patient was admitted to a hospital and, if so, what was the diagnosis; 3) who was responsible for the nontransport decision (patient, paramedic, or mutual); and 4) how satisfied the patient was with the EMS service. After six weeks of data collection, the results were presented in a nonjudgmental fashion to the paramedics. After this intervention, the data collection continued for another five weeks without the paramedics' knowledge. Results. After the intervention, the overall nontransport rate remained constant (11.5% vs. 10.7%). The percentage of patients seeking further medical attention within 24 hours also remained constant (37.1% vs. 33.9%). The percentage of patients who required hospitalization within 24 hours of the nontransport declined from 12.6% to 6.4%. The percentage of patients who refused ambulance transportation by paramedics declined from 9.3% to 3.7%. Overall satisfaction level rose from 94.7% to 100%. Conclusion. When paramedics were provided with objective feedback regarding outcome of patients not transported, the paramedic-initiated nontransportation and delayed hospitalization rates decreased, and the patient satisfaction level rose to 100%. PREHOSPITAL EMERGENCY CARE 2002;6:31-35
Prehospital refusal-of-transport policies: Adequate legal protection?
2000, Prehospital Emergency CareObjectives. To determine the percentage of EMS systems utilizing formal refusal-of-transport policies and to evaluate the adequacy of these policies as a means of protection against potential litigation. Methods. A scripted, closed-ended, 17-question survey was administered to EMS representatives in the 100 most heavily populated U.S. cities. This survey focused on four main areas: utilization of formal refusal-of-transport policies, criteria for the establishment of patient competence, supervision of field personnel while carrying out refusal-of-transport policies, and documentation requirements. Results: Eighty-six of 100 (86%) EMS representatives participated. Ten (10%) were unreachable, and four (4%) refused to participate. Seventy-eight of the 86 EMS services (91%) utilized formal refusal-of-transport policies. Eighty-three percent (65 of 78) mandated establishment of patient competence. Orientation to person, place, and time was utilized by 97% (63 of 65), lack of alcohol intoxication by 66% (43 of 65), comprehension of the nature of the medical condition by 58% (38 of 65), comprehension of the risks and benefits of treatment by 48% (31 of 65), clear speech by 42% (27 of 65), and lack of head trauma by 3% (2 of 65). Age-appropriate behavior, emotional control, and no loss of consciousness were each employed in 2% (1 of 65) of these policies. Fifteen percent of the 65 policies studied required contact with a physician, 5% with a supervisor, and 1% with the police. Ninety-nine percent of these policies required the patient to sign a statement of refusal, while 81% required documentation of vital signs. Only 32% of these policies contain all of the elements recommended in the medical and legal literature. Conclusion: The majority of EMS systems surveyed have adopted formal policies to guide field personnel in the management of patient refusals. Fewer than a third of these policies contain all of the elements shown to be protective against legal challenge. PREHOSPITAL EMERGENCY CARE 2000;4:53-56
Claims against a paramedic ambulance service: A ten-year experience
1999, Journal of Emergency MedicineLiability claims made against Emergency Medical Services (EMS) agencies are a source of significant anxiety, time expenditure, and often monetary loss. Past literature reviewing EMS liability has been limited in scope. In this study, all claims made against an urban 911 ambulance service, whether or not a lawsuit resulted, were analyzed for the 10-year period ending in 1993. Eighty-two claims resulting in 11 lawsuits were filed. Motor vehicle accidents involving an ambulance produced the overwhelming majority (72%) of claims and 53% of the dollars paid out. Medical negligence claims were few but were the next largest cause of dollars lost (35%). Review of all legal claims may be used to help guide risk management efforts.