Patient Safety Culture and Error
The State of Safety in Paramedicine
Unlike the highly regulated hospital environment, the out-of-hospital setting is unpredictable and lacks fixed safety infrastructure. Lydon et al. (2023) highlight that measuring safety in EMS often relies on "lagging indicators" (reactive measures like past harm) and non-clinical metrics (response times) rather than "leading indicators" (proactive precursors to safety).
The Challenge: Patients in the EMS setting often lack a clinical history, meaning paramedics rely heavily on bystanders/family for information, increasing the risk of diagnostic error.
Blame Culture vs. Just Culture
Meadley et al. (2023) argue that paramedicine has historically suffered from a Blame Culture, where individuals are shamed or punished for errors. This leads to:
- Under-reporting of near misses and adverse events.
- Fear of retribution or "fitness to practice" investigations.
- Decreased staff wellbeing and increased turnover.
- Loss of opportunities for system-wide learning.
The Shift to Just Culture: A Just Culture balances system accountability with individual accountability. It recognizes that most errors are caused by system breakdowns (e.g., poor protocols, fatigue, equipment design) rather than individual recklessness. It asks "What happened?" not "Who did it?".
Hierarchy of Safety Interventions
To improve safety, interventions must move from "person-focused" to "system-focused" (Lydon et al., 2023):
- Forcing Functions (Most Effective): Designing equipment so errors are impossible (e.g., Luer locks that don't fit wrong ports).
- Automation/Computerisation: Electronic Patient Care Records (ePCR) to flag contraindications.
- Standardisation: Consistent equipment layouts in every ambulance.
- Checklists: Zero Point Survey, RSI checklists.
- Education/Training (Least Effective): Relies on fallible human memory.
Human Factors in Paramedicine
Human factors involves understanding how humans interact with other elements of a system. It acknowledges human limitations (fatigue, stress, cognitive bias) and designs systems to support human performance.
| Factor Type | Examples in Paramedicine |
|---|---|
| Emotional & Behavioural | Emotional intelligence, empathy, resilience, confidence, and stress response. |
| Cognitive | Decision-making, attention, memory, cognitive biases (e.g., confirmation bias, anchoring), and situational awareness. |
| Social & Cultural | Interpersonal dynamics, power gradients, and cultural sensitivity. |
| Teamwork | Leadership styles, followership, and communication loops. |
| Environmental | Noise, lighting, weather, confined spaces, and bystanders. |
Cognitive Load Theory (CLT)
The Working Memory Bottleneck
Working Memory is limited (holding roughly 4-7 items at once). Long-Term Memory is effectively unlimited. Learning involves processing information in working memory to create "schemas" in long-term memory.
Cognitive Overload occurs when the total cognitive load exceeds the capacity of working memory. In paramedicine, this leads to tunnel vision, poor decision-making, and error.
1. Intrinsic Load
The inherent difficulty of the task itself.
Example: Calculating a complex paediatric drug dose while managing an airway.
Management: Can only be reduced by increasing expertise (training) so tasks become automated.
2. Extraneous Load
The load generated by the way information is presented or the environment. It does not aid learning or performance.
Example: A chaotic scene, poorly designed monitor displays, shouting bystanders, disorganized kit bags.
Management: Reduce noise, declutter the scene, use checklists, standardize equipment layout.
Strategies to Optimize Cognitive Load
- "Eyes on, Eyes off": Delegating monitoring tasks to technology or partners to free up mental space.
- Standardisation: Keeping kit bags packed identically reduces the search effort (extraneous load).
- Automation: Practicing skills (e.g., cannulation) until they are automatic reduces the intrinsic load, freeing up capacity for critical decision making.
- Cognitive Offloading: Using cognitive aids (apps, cheat sheets) instead of relying on memory.
Situation Awareness (Endsley's Model)
Situation Awareness (SA) is knowing what is going on around you. It is critical for patient safety.
Three Levels of SA
- Level 1: Perception (Scanning)
Noticing cues. Example: Seeing the patient is pale and the monitor shows HR 130. - Level 2: Comprehension (Understanding)
Integrating cues to understand the current state. Example: Recognizing the patient is in decompensated shock. - Level 3: Projection (Predicting)
Forecasting future status. Example: "This patient will likely arrest if we RSI without resuscitation first."
The Zero Point Survey (ZPS)
A strategy to mitigate cognitive overload and optimize team performance before touching the patient. It moves beyond the traditional "Danger" check to a structured preparation phase.
The STEP UP Framework
Pre-Resuscitation Phase (The Zero Point):
- S - Self: "I'm SAFE" (Illness, Medication, Stress, Alcohol, Fatigue, Eating). Cognitive readiness (Breathe, Talk, Focus).
- T - Team: Identify Team Leader. Allocate Roles. Briefing.
- E - Environment: Control the space (Light, Noise, Crowd, Access). "Resuscitative Real Estate".
Resuscitation Commenced:
- P - Patient: The standard Primary Survey (ABCDE).
- U - Update: Share the mental model. "We have a 40yo male with tension pneumothorax."
- P - Priorities: Set mission trajectory. "Priority is decompression and transport."
SEIPS: Systems Engineering Initiative for Patient Safety
Understanding the Work System
SEIPS is a framework for understanding outcomes within complex socio-technical systems. It posits that Outcomes (patient safety, staff wellbeing) are the result of Processes (work done), which are shaped by the Work System.
Components of the Work System
Errors occur due to interactions between these components. In simulation, use this to find Latent Safety Threats (LSTs)—accidents waiting to happen.
- Person(s): Skills, knowledge, fatigue, stress levels of the paramedics.
- Tasks: Complexity, ambiguity, time pressure of the clinical procedure.
- Tools & Technology: Usability of equipment, reliability of monitors, portability of bags.
- Internal Environment: Lighting, noise, space, layout of the ambulance.
- Organization: Protocols, staffing levels, safety culture, schedules.
- External Environment: Policy, regulatory demands, societal factors.