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PATIENT SAFETY IN EMERGENCY MEDICAL SERVICES: A SYSTEMATIC REVIEW OF
THE LITERATURE
Blair L. Bigham, BSc, MSc, ACPf, Jason E. Buick, BSc, Steven C. Brooks, MD, MSc, FRCPC,Merideth Morrison, ACP, Kaveh G. Shojania, MD, FRCPC,
Laurie J. Morrison, MD, MSc, FRCPC
ABSTRACT
Background. Preventable harm from medical care has beenextensively documented in the inpatient setting. Emergencymedical services (EMS) providers care for patients in dy-namic and challenging environments; prehospital emer-gency care is a field that represents an area of high risk
Received April 30, 2011, from Rescu, Keenan Research Centre, LiKa Shing Knowledge Institute, St. Michael’s Hospital (BLB, JEB,SCB, LJM), Toronto, Ontario, Canada; the Department of Health Pol-icy, Management and Evaluation, Faculty of Medicine, Universityof Toronto (JEB, LJM), Toronto, Ontario, Canada; the Departmentof Emergency Services, Sunnybrook Health Sciences Centre (SCB),Toronto, Ontario, Canada; the Division of Emergency Medicine,Department of Medicine (SCB, KGS, LJM), University of Toronto,Toronto, Ontario, Canada; the County of Simcoe Paramedic Services(MM), Barrie, Ontario, Canada; the Centre for Patient Safety, Uni-versity of Toronto (KGS), Toronto, Ontario, Canada; and the De-partment of Medicine, University of Toronto (KGS, LJM), Toronto,Ontario, Canada. Revision received August 21, 2011; accepted forAugust 23, 2011.
Presented in abstract form at the National Association of EMS Physi-cians annual meeting, Jacksonville, Florida, January 2009, and par-tially as a government report at www.patientsafetyinstitute.ca. Notpreviously published in a peer-reviewed source.
Supported by the Canadian Patient Safety Institute (CPSI), the Emer-gency Medical Services Chiefs of Canada (EMSCC), and the CalgaryEMS Foundation.
Carolyn Ziegler, Information Specialist at St. Michael’s Hospital, as-sisted with the development and execution of the literature search.Ajay Parekh provided library services. The Patient Safety Pan-Canadian Patient Safety in EMS Advisory Group played a key rolein developing the search strategy. This group was chaired by JoeAcker, EMSCC Board of Directors, and included Dr. Andy Anton,Paula Beard, Ian Blanchard, Ron Bowles, Dr. Ken Bucholz, Pierre De-schamps, Orvie Dingwall, Tom Dobson, Paula Greco, Lyle Karasiuk,Sandi Kossey, John Lewis, Dr. Russell MacDonald, Marie Owen, Dr.Brian Schwartz, Bryan Singleton, and Jennifer Wheaton. More infor-mation about this Advisory Group can be found on the CPSI Websiteat www.patientsafetyinstitute.ca. Sandi Kossey, CPSI, provided ad-ditional support and guidance.
The authors report no conflicts of interest.
Reprints are not available.
Address correspondence to: Blair Bigham, BSc MSc, ACPf, Rescu,Keenan Research Centre, Li Ka Shing Knowledge Institute, St.Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B1W8. e-mail: [email protected]; web: www.rescu.net
doi: 10.3109/10903127.2011.621045
for errors and harm, but has received relatively little atten-tion in the patient safety literature. Objective. To identifythe threats to patient safety unique to the EMS environmentand interventions that mitigate those threats, we completeda systematic review of the literature. Methods. We searchedMEDLINE, EMBASE, and the Cumulative Index to Nurs-ing and Allied Health Literature (CINAHL) for combinationsof key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. Weexcluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an inde-pendent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic toexamine interrater agreement. Any differences were resolvedby consensus. Results. We retrieved 5,959 titles, and 88 pub-lications met the inclusion criteria and were categorized intoseven themes: adverse events and medication errors (22 arti-cles), clinical judgment (13), communication (6), ground ve-hicle safety (9), aircraft safety (6), interfacility transport (16),and intubation (16). Two articles were randomized controlledtrials; the remainder were systematic reviews, prospectiveobservational studies, retrospective database/chart reviews,qualitative interviews, or surveys. The kappa statistics fortitles, abstracts, and full-text articles were 0.65, 0.79, and0.87, respectively, for the first search and 0.60, 0.74, and 0.85for the second. Conclusions. We found a paucity of scien-tific literature exploring patient safety in EMS. Research isneeded to improve our understanding of problem magni-tude and threats to patient safety and to guide interventions.Key words: emergency medical services; ambulance; prehos-pital; patient safety; medication error; adverse event; system-atic review
PREHOSPITAL EMERGENCY CARE 2012;16:20–35
INTRODUCTION
Emergency medical services (EMS) providers respondto thousands of 9-1-1 calls each day, caring for patientsin challenging, unpredictable, and potentially danger-ous environments night and day. After rushing to theoften unfamiliar scene, these providers engage in cri-sis situations that are hectic, rushed, and primed withstress. Unlike caregivers in any other health care dis-cipline, EMS providers work in perhaps the least idealphysical and emotional environment, creating a milieuripe for patient harm.1
Reducing the risk of unnecessary harm, such aserrors of omission or commission, associated withhealth care to an acceptable minimum has been termed
20
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Bigham et al. PATIENT SAFETY IN EMS SYSTEMATIC REVIEW 21
“patient safety.”2 The epidemiology of patient safetyproblems in the inpatient, mental health, and nurs-ing home settings has received considerable attentionin the literature.3–5 According to the seminal Instituteof Medicine report To Err Is Human,6 a million peo-ple are harmed by health care errors each year in theUnited States, and a further 120,000 die from those er-rors, with more events going unreported.7 The cost as-sociated with these patient safety threats exceeds $17billion (2008).8 Despite its nature, EMS is seldom dis-cussed in the patient safety literature.
The primary objective of this study was to performa systematic review of published literature to iden-tify recognized threats to patient safety in EMS, withthe intention to inform EMS operators, physicians, andpolicymakers who design and manage EMS systems.
METHODS
Data Sources and Search Strategy
We conducted a systematic review of the literatureto identify threats to the safety of patients exposed tothe EMS system. We also sought to identify reportsof strategies aiming to mitigate risk of harm relatedto recognized EMS patient safety threats. Our processfollowed the Cochrane methodology.9 We searchedthe MEDLINE, EMBASE, and Cumulative Index toNursing and Allied Health Literature (CINAHL)databases from January 1, 1999, to March 1, 2011, forall relevant articles. We chose 1999 as the inceptionyear because it was the year in which the Institute ofMedicine released its report To Err Is Human.6 To findall relevant citations related to patient safety in EMS,search strategies were formulated using medical sub-ject headings and text words that combined terms forboth patient safety and EMS (Appendix 1 - availableonline). The search strategy was developed by a pan-Canadian group of EMS and patient safety experts andan information specialist.1,10 We identified additionalpotential articles by hand-searching bibliographies ofall included articles and contacting experts in bothprehospital care and patient safety. We met with anadvisory board of patient safety experts and EMSoperators over four conference calls to ensure thesearch terms had face validity and the preliminarysearch results included key articles known to directlyor indirectly address the problem.
Data Selection
We included all studies that addressed a patientsafety issue in the EMS setting. Patient safety issuesincluded any component of EMS care that couldharm a patient, but did not include studies of specifictherapies or specific illnesses. We also included allstudies that examined an intervention aimed at re-
ducing the risk of identified patient safety threats.Any article with a reported research methodologywas eligible; we excluded abstract-only publications,opinion articles, commentaries, and letters to the edi-tor. Non-English articles were also excluded. Becauseof the large reported literature on intubation, variousprocedural techniques, and indications for a broadpopulation, it was decided a priori to devote a theme tointubations. Other specific therapies were excludedbecause of their limited applicability in the prehospitalsetting. Each eligible citation was blindly reviewedindependently by two investigators in a hierarchicalmanner from January 1, 1999, to January 26, 2009(BLB and SCB), and from January 27, 2009, to March1, 2011 (BLB and JEB). Unexpected investigator timecommitments led to the addition of a third reviewer tocomplete the screening. Titles classified as “include”or “indeterminate” by at least one of the investiga-tors were included in the blinded abstract review.A similar blinded process occurred to identify fullarticles. Disagreements at the full-article stage wereresolved by discussion and consensus between thereviewing authors. We used Cohen’s kappa statistic ateach phase of our review (title, abstract, and full text)to evaluate agreement between raters for each timeperiod separately.
Data Extraction
Two investigators (BLB and MM) independently ab-stracted information from each article using a prede-fined data-abstraction tool that was developed by theinvestigators and captured the following: the studydesign (if applicable), the population demographics,the patient safety concern examined (control), the in-tervention (if applicable), outcome data, the type ofEMS provider, and the EMS setting involved. Any ab-straction differences were resolved through consen-sus. All patient safety data abstracted were categorizedinto common themes through consensus between thetwo abstracting authors. The organization of the arti-cles into themes was reviewed for face validity by twoother investigators (SCB and LJM).
RESULTS
Search Yield
The search yielded 5,959 article titles; 1,039 abstractswere reviewed; and 257 articles were identified to un-dergo full-text review (Fig. 1). Of these, 88 papers metthe inclusion criteria and were included in the review.Cohen’s kappa statistics measuring interrater agree-ment for titles, abstracts, and full-text articles were0.65, 0.79, and 0.87, respectively, for the first time pe-riod (January 1, 1999, to January 26, 2009) and 0.60,0.74, and 0.85 for the second time period (January 27,2009, to March 1, 2011).
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22 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2012 VOLUME 16 / NUMBER 1
5,959 Citations identified
within search
257 Citations reviewed
by full article
4,920 Citations excluded
based on title
782 Citations excluded based on abstract
88 Citations included
in review
26 Citations excluded
(non-English)
143 Citations excluded
(did not meet inclusion criteria)
FIGURE 1. Flowchart of the review process.
The articles were categorized into seven themes(Table 1), the methodologies of which were highlyvariable (Table 2). Themes included clinical judgment(Table 3), adverse events and error reporting (Table 4),communications (Table 5), ground vehicle safety (Table6), aircraft safety (Table 7), interfacility transport (Table8), and field intubation (Table 9). Data (population, in-tervention, control, outcomes) were abstracted and arepresented in Tables 3–9. The heterogeneity of the meth-ods, populations, interventions, controls, and outcome
TABLE 1. Patient Safety Themes Emerging from theLiterature
Theme Number of Articles
Clinical judgment 1311,18,26–36
Adverse events and error reporting 2212, 37–57
Communications 658–63
Ground vehicle safety 923,64–71
Aircraft safety 672–77
Interfacility transport 1678–93
Field intubation 1694–109
The systematic review yielded 88 papers describing these seven themes ofpatient safety in emergency medical services.
measures across studies was substantial and did notallow for meta-analysis.
Population
Reviewers determined that most articles quantitativelyexamined clinical adverse events occurring in patients,while few qualitatively explored attitudes and habitsamong EMS and other health care providers. Patientgroups varied; ages included neonatal to geriatric co-horts, conditions included “all callers” to specific pa-tient subgroups, and chronologic location in the con-tinuum of care ranged from 9-1-1 callers to interfacilitytransfer patients. Provider populations varied as well;ages, experience levels, and certifications (emergencymedical technicians, paramedics, critical care transferstaff, nurses, and physicians) varied across studies.
Control Groups and Interventions
In the only randomized controlled trial (RCT) examin-ing patients, Mason et al. compared safety outcomesof ambulance patients >59 years of age who receivedtreatment from standard paramedics versus extended-scope paramedics who had received additional train-ing in the management of low-acuity conditions.11 Ina simulation-based RCT, Bernius et al. compared theability of experienced paramedics to calculate drugdoses before and after the implementation of a drugreference card.12
Outcomes
Patient safety outcomes ranged from physiologic vari-ables (heart rate, blood pressure, oxygen saturation,etc.) and equipment malfunction rates (defibrillators,stretchers, aircraft, etc.) to perceived barriers in self-reporting adverse events (culture, fatigue, policies,etc.). Other outcomes examined patient discourse(readmission, death, etc.), information exchange (indispatch, at transfer of care, etc.), and technical skill ac-curacy (medication dose calculation, endotracheal in-tubation success rates, etc.). Outcomes for each studyare listed by theme in Tables 3–9.
DISCUSSION
We set out to identify recognized patient safety is-sues in the prehospital setting and interventions thataim to reduce the incidence or mitigate the impact ofsuch events. We found surprisingly few studies ex-amining a very narrow range of EMS patient safetythemes exploring “low-hanging fruit”—topics that areeasy to retrospectively review, such as vehicle colli-sions, medication errors and esophageal intubations,or qualitative questions surrounding adverse event
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(Con
tinu
edon
next
page
)
25
Preh
osp
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erg
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/03/
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licab
le.
26
Preh
osp
Em
erg
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cMas
ter
Uni
vers
ity o
n 11
/03/
14Fo
r pe
rson
al u
se o
nly.
Bigham et al. PATIENT SAFETY IN EMS SYSTEMATIC REVIEW 27
TABLE 5. Theme 3—Communications (n = 6)
Citation Method N Population Intervention Control Outcome
Bost et al. 201058 Systematicreview
8 studies Prehospital andin-hospital staff
N/A N/A Themes related to clinicalhandover of prehospitalpatients to the ED werereviewed.
Carter et al. 200959 Prospectiveobservationalstudy
96 Trauma patienthanded overfrom EMS to ED
N/A N/A Information loss betweenEMS and ED staff duringtrauma patient handoverwas described.
Evans et al. 201060 Prospectiveobservationalstudy
25 Trauma patienthanded overfrom EMS to ED
N/A N/A Information loss betweenEMS and ED staff duringtrauma patient handoverwas described.
Owen et al. 200961 Qualitativeinterviews
Paramedics: 19,nurses: 15,doctors: 16
Prehospital andin-hospital staff
N/A N/A Recommendations onmaximizing handovereffectiveness between EMSand ED staff were derived.
Vilensky andMacDonald 201162
Prospectiveobservationalstudy
98 Requests for airmedicaltransfers
N/A N/A Communication-based errorswere classified andreported.
Zimmer et al. 201063 Prospectiveobservationalstudy
40 ALS paramedicteamsparticipating insimulations
N/A N/A Adverse events andinformation loss duringprehospital caresimulations weredescribed.
Papers related to patient safety and prehospital communications (n = 6).ALS = advanced life support; ED = emergency department; EMS = emergency medical services; N/A = not applicable.
reporting. It appears that EMS patient safety researchis in its infancy. We consider this a sign of matura-tion of EMS research and an indication that prehospitalpatient safety is at least of interest to EMS providers,operators, physicians, and patient safety experts.While these adverse events and attitudinal studies area good place to start, EMS needs to dedicate resourcesto address patient safety and seek advice from otherdisciplines in medicine to expand the EMS industry’sunderstanding of patient safety and expedite the re-search and implementation of effective safety improve-ment initiatives.
Comparing the content of our findings with a tax-onomy for organizing patient safety literature showsseveral gaps; research into prehospital staffing, safetyculture, near-miss reporting, nosocomial infections,quality improvement techniques, and human factorsengineering is lacking.13 Further, interventions target-ing safety improvements are seldom reported. This isin contrast to other disciplines, where a broad rangeof patient safety themes have been addressed with in-terventional study designs. For example, introducingbar code scanners to reduce medication errors in thehospital setting led to a relative error reduction of 51%(p < 0.001).14 Implementation of a surgical safetychecklist in eight cities around the world led to areduction in mortality from 1.5% to 0.8% (p = 0.003)and reduced complication rates from 11% to 7%(p < 0.001).15 This checklist was completed by thesurgical team before, during, and after the surgicalprocedure to ensure that mission-critical details were
not overlooked. A study involving 103 intensive careunits studied the effect of a best practices “bundle”to reduce central line infections and identified a dropin the mean infection rate per 1,000 catheter daysfrom 7.7 to 1.4 (p < 0.002).16 The implementation ofa medical team training program that highlighted acrew resource management model adapted for healthcare by aviation in the operative setting was associatedwith a reduction in surgical mortality (relative risk[RR] 1.49, 95% confidence interval [CI] 1.10–2.07).17
Here, interventions to change behavior, to includetraining in closed-loop communication strategies anda facilitated breakdown of historical hierarchies, wereimplemented through well-designed studies to reducemisunderstanding and encourage staff to communi-cate their concerns. While not all of these interventionsdirectly translate to EMS, creative thinking was used todesign interventions that addressed patient safety con-cerns, and significant reductions in harm were accom-plished. Interventions to reduce safety threats in EMSare lacking but are by no means unattainable. Patientsafety interventions that work in the critical care units,emergency departments, neonatal intensive care units,and operating rooms may have some applicability tothe EMS setting, and adaptations of effective interven-tions can be studied rather than starting de novo.
Another area requiring more study in the prehospitalliterature surrounds clinical decision making by EMSproviders. Atack and Maher asserted that, with recentadvances in the scope of practice of EMS providers,clinical decision-making ability may be a significant
Preh
osp
Em
erg
Car
e D
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d fr
om in
form
ahea
lthca
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cMas
ter
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vers
ity o
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/03/
14Fo
r pe
rson
al u
se o
nly.
28 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2012 VOLUME 16 / NUMBER 1
TABLE 6. Theme 4—Ground Vehicle Safety (n = 9)
Citation Method N Population Intervention Control Outcome
Becker et al. 200364 Retrospectivereview
305 Ambulances, fireapparatus,police cars inU.S. crashdatabases1988—1997
N/A N/A Comparison of vehiclecollisions between fire,police, and EMS.
Bull et al. 200165 Prospectiveexperiment
30 Infant manikins(8 kg),3-year-oldmanikins (18kg), 6-year-oldmanikins (27kg)
Various backrestand seat-beltpositions
N/A Quality of restraint wasdescribed.
De Graeve et al.200366
Observationalbefore–afterstudy
Not reported Ground 9-1-1–intensivecare units(2nd tier)staffed byphysicians
Briefing withdrivers ondriving habits
FleetLoggeronboard datarecorderinstalled onMICUs
Occurrence of “risky”behaviors: speed andharsh braking werecompared betweencohorts.
Johnson et al. 200667 Survey tool 302/446 Ground EMSproviders
N/A N/A Knowledge and trainingpatterns regardingpediatric restraintswere self-reported.
Kahn et al. 200123 Retrospectivereview
339 events, 405deaths, 838other injuries
All fatalities andinjuries from aU.S.ambulancecrash database1987–1997
N/A N/A Characteristics ofambulance crasheswere described.
King et al. 200268 Survey tool 90/153 Managers fromground andair pediatrictransferservices
N/A N/A Adverse event rates andsafety practices wereself-reported.
Levick and Swanson200569
Prospectiveobservationalstudy
36 ambulance-sand >250drivers
Ground EMS Real-timeauditoryfeedback todriver
No feedback Frequencies of traffic ruleviolations weremeasured.
Ray and Kupas200771
Retrospectivereview
311 rural and1,434 urban
Collisions ofEMS vehicles
N/A N/A EMS collisions in ruraland urban areas werecompared.
Ray and Kupas200570
Retrospectivereview
2,038 EMS and23,155controls
Collisions ofEMS andsimilar-sizedvehicles
N/A N/A Collisions between EMSand similar-sizedvehicles werecompared.
Papers related to patient safety and ground vehicle safety (n = 9).EMS = emergency medical services; MICU = mobile intensive care unit; N/A = not applicable.
threat to patient safety. This qualitative work hassuggested that EMS providers may be making de-cisions that they are not trained to make, i.e., deci-sions that have perhaps outpaced the foundation ofmedical education and clinical training of EMSproviders. The impact of this “scope creep” may leadproviders to make decisions that could harm patientsduring prehospital care.18 The problem of cognitive er-ror is not unique to EMS; diagnostic decision-makingweaknesses have been addressed in both physiciansand nurses as well.19,20
There is encouraging attention by the EMS commu-nity to enhancing patient safety; in 2010, the NationalHighway Traffic Safety Administration partnered with
the American College of Emergency Physicians to pro-mote an “EMS Culture of Safety,” and a 2009 Summiton Patient Safety hosted in partnership with the EMSChiefs of Canada and the Canadian Patient Safety In-stitute identified nine strategic priorities to improvepatient safety and enhance research activities relatedto harm reduction and safety.21 Acting on these priori-ties will improve the patient safety research enterprisein two ways. First, by encouraging high-quality datareporting and the use of standardized definitions,22
EMS systems will accumulate data allowing for com-parisons within and between systems. Key to this com-prehensive data capture is a “cultural shift” amongboth leaders and care providers where adverse events
Preh
osp
Em
erg
Car
e D
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rson
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nly.
Bigham et al. PATIENT SAFETY IN EMS SYSTEMATIC REVIEW 29
TABLE 7. Theme 5—Aircraft Safety (n = 6)
Citation Method N Population Intervention Control Outcome
Bledsoe and Smith200472
Retrospectivereview
84 All medical helicopteraccidents in twoU.S. databases1993–2002
N/A N/A Rates of and contributorsto air crashes aredescribed.
De Lorenzo et al.199973
Retrospectivereview
13.13 millionflight hours
Records pertaining toall flight hoursbetween 1987 and1995 flown by theU.S. Army
Medical flighthours
Nonmedicalflight hours
Crash rates werecompared.
Dery et al. 200774 Survey tool 806 complete Nonrandomizedsampling of U.S.helicopter EMSpilots
N/A N/A Data regarding CrewResource Managementtraining and opinionsfor factors involved inEMS accidents wereself-reported.
Frakes and Kelly200775
Survey tool 126/200 U.S. helicopter EMSemployees
N/A N/A Adherence to best safetypractices wasself-reported.
Thies et al. 200676 Survey tool andretrospectivereview
Civil EMS helicoptercrashes reported tothe GermanAviation Authority1980–2001
N/A N/A Rates of and contributorsto air crashes aredescribed.
Thomas et al. 200577 Survey tool 508 Administrators,aviation experts,and cliniciansinvolved inaeromedicaltransport
N/A N/A Perceived issues inaeromedical safety wereself-reported.
Papers related to patient safety and aircraft safety (n = 6).EMS = emergency medical services; N/A = not applicable.
are discussed without fear of retribution and exam-ined from a systems perspective. This self-reporteddata will shine a light on adverse events and will guidefuture interventional research. Second, the prioritiessuggest that increased human resource capacity in re-search and patient safety through more graduate train-ing of EMS professionals will help develop a cadre ofparamedic researchers who can increase the amount ofscientific research being conducted.
Patient safety in EMS, as a field of study and practice,now needs to move forward by clarifying the types,frequency, and impact of threats to patient safety thatoccur specifically in the EMS setting. This may be facil-itated with the application of standardized taxonomyand methodologies to the study of patient safety inEMS.22 Systems and processes must be put in place tobetter define threats to patient safety specific to EMS,and rigorous research-quality databases are needed totrack adverse events in the prehospital setting.21 As thesafety landscape becomes defined, interventions to im-prove EMS practice can be collaboratively developed,evaluated, and implemented.
A modest number of research studies were relatedto provider safety, which was excluded from thisreview.23–25 Research addressing injury of providerswhile lifting patients, driving, or administering med-ication was not included in this review, though we ac-
knowledge that it is possible that adverse events af-fecting patient safety could stem from events that alsothreaten the safety of providers. This is an area de-serving greater attention by researchers and operatorsalike.
LIMITATIONS
Limitations to this review include publication bias andexclusion of non-English articles and abstracts not ac-companied by a manuscript. This review only includedarticles that addressed patient safety specific to theEMS setting. By applying these criteria, we have ex-cluded patient safety literature that may be extrapo-lated to address patient safety issues in EMS. Manyinterventions currently used in other health care set-tings may well be directly applicable to EMS, whileothers may require validation before broad implemen-tation in EMS. For instance, a validated interventionto reduce drug dosing errors by nurses for postopera-tive patients in the hospital may be appropriate for useby paramedics in the prehospital setting, whereas var-ious checklists derived for the operating room may nottranslate well to the fast-paced field setting in whichEMS providers work.
Preh
osp
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rson
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nly.
TA
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tyTr
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.200
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ents
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edic
alcr
ew
Tran
sfer
red
pati
ents
who
coul
dha
vere
ceiv
edin
terv
enti
ons
atth
ese
ndin
gfa
cilit
y
Tran
sfer
red
pati
ents
adm
itte
dto
ICU
Rea
sons
for
and
outc
omes
afte
rin
terf
acili
tytr
ansp
orta
rere
port
ed.
Fan
etal
.200
681Sy
stem
atic
revi
ew5
stud
ies
Air
and
grou
ndin
terf
acili
tytr
ansf
erpa
tien
tsN
/A
N/
AA
syst
emat
icre
view
ofad
vers
eev
ents
inin
terf
acili
tytr
ansp
ort.
Flab
ouri
set
al.2
00682
Pros
pect
ive
coho
rtst
udy
272
Pati
ents
from
4gr
ound
and
air
inte
rfac
ility
tran
spor
tgro
ups
Ad
vers
eev
entr
epor
tfo
rmN
/A
Rat
esan
dco
ntri
buto
rsto
adve
rse
even
tsw
ere
reco
rded
.Fr
ied
etal
.201
083R
etro
spec
tive
revi
ew2,
396
Ad
ulti
nter
faci
lity
pati
ents
tran
sfer
red
bygr
ound
crew
N/
AN
/A
Ad
vers
eev
entr
ates
wer
ere
cord
ed.
Geb
rem
icha
elet
al.
2000
84R
etro
spec
tive
revi
ew39
Inte
rfac
ility
pati
ents
tran
sfer
red
byph
ysic
ians
N/
AN
/A
Ad
vers
eev
entr
ates
dur
ing
tran
spor
twer
ere
cord
ed.
Hat
heri
llet
al.2
00385
Ret
rosp
ecti
vere
view
202
Ped
iatr
icpa
tien
tstr
ansf
erre
dby
air
orgr
ound
para
med
ics
orph
ysic
ians
toin
tens
ive
care
N/
AN
/A
Ad
vers
eev
entr
ates
wer
ere
cord
ed.
Lee
etal
.200
886Pr
ospe
ctiv
eob
serv
atio
nals
tud
y10
2A
dul
tpat
ient
str
ansf
erre
dby
aph
ysic
ian
grou
ndin
terf
acili
tyte
am
App
licat
ion
ofsc
ores
topr
edic
tdet
erio
rati
onN
/A
Two
scor
esw
ere
appl
ied
toin
terf
acili
typa
tien
ts,a
ndco
mpa
red
betw
een
pati
ents
who
det
erio
rate
dan
dth
ose
who
did
not.
Lee
san
dE
lcoc
k20
0887
Ret
rosp
ecti
vere
view
555
Car
dia
cpa
tien
tstr
ansf
erre
dby
anu
rse,
para
med
ic,o
rph
ysic
ian
via
grou
ndor
air
N/
AN
/A
Req
uire
men
tfor
med
ical
inte
rven
tion
dur
ing
tran
spor
tw
asre
cord
ed.
Lig
tenb
erg
etal
.20
0588
Pros
pect
ive
coho
rtst
udy
100
Inte
rfac
ility
tran
sfer
pati
ents
bya
phys
icia
nN
/A
N/
AA
dve
rse
even
trat
esw
ere
reco
rded
.L
iman
dR
atna
vel
2008
89Pr
ospe
ctiv
eco
hort
stud
y34
6A
llem
erge
ntne
onat
alin
terh
ospi
talt
rans
fers
Ad
vers
eev
ent
repo
rtin
gfo
rmN
/A
Rat
esan
dco
ntri
buto
rsto
adve
rse
even
tsw
ere
reco
rded
.L
impr
ayoo
net
al.
2005
90R
etro
spec
tive
revi
ew36
Inte
rfac
ility
pati
ents
<14
year
str
ansp
orte
dby
grou
ndnu
rses
and
para
med
ics
N/
AN
/A
Ad
vers
eev
entr
ates
wer
ere
cord
ed.
Lin
den
etal
.200
191Pr
ospe
ctiv
eob
serv
atio
nals
tud
y29
Pati
ents
onex
trac
orpo
real
mem
bran
eox
ygen
atio
n(E
CM
O)t
rans
port
edby
am
obile
EC
MO
team
bygr
ound
orai
r
N/
AN
/A
Ad
vers
eev
entr
ates
dur
ing
tran
spor
twer
ere
cord
ed.
Mos
set
al.2
00592
Ret
rosp
ecti
veco
hort
stud
y2,
402
Neo
nata
lint
erfa
cilit
ygr
ound
tran
spor
tsby
aph
ysic
ian
Part
ners
hips
toen
sure
ambu
lanc
eav
aila
bilit
y
Part
ners
hip
noti
npl
ace
Ad
vers
eev
entr
ates
wer
eco
mpa
red
betw
een
the
two
coho
rts.
Uus
aro
etal
.200
290R
etro
spec
tive
revi
ew66
Inte
rfac
ility
resp
irat
ory
failu
repa
tien
tstr
ansf
erre
dby
aph
ysic
ian
N/
AN
/A
Ad
vers
eev
entr
ates
wer
ere
cord
ed.
Pape
rsre
late
dto
pati
ents
afet
yan
din
terf
acili
tytr
ansp
ort(
n=
16).
ICU
=in
tens
ive
care
unit
;N/
A=
nota
pplic
able
.
30
Preh
osp
Em
erg
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cMas
ter
Uni
vers
ity o
n 11
/03/
14Fo
r pe
rson
al u
se o
nly.
TA
BL
E9.
The
me
7—Fi
eld
Intu
bati
on(n
=16
)
Cit
atio
nM
etho
dN
Popu
lati
onIn
terv
enti
onC
ontr
olO
utco
me
Bai
ret
al.2
00594
Ret
rosp
ecti
vech
art/
dat
abas
ere
view
1,64
3in
tuba
tion
sPa
tien
tsin
tuba
ted
bygr
ound
EM
Spa
ram
edic
sN
/A
N/
AE
ndot
rach
ealt
ube
plac
emen
twas
asse
ssed
onar
riva
lath
ospi
talb
yE
Dph
ysic
ian.
DiR
usso
etal
.200
595R
etro
spec
tive
revi
ew5,
460
Trau
ma
pati
ents
<20
year
str
ansp
orte
dto
ped
iatr
ictr
aum
ace
nter
N/
AN
/A
Rel
atio
nof
end
otra
chea
lint
ubat
ion
tocl
inic
alan
dop
erat
iona
lout
com
esw
asas
sess
ed.
Fakh
ryet
al.2
00696
Ret
rosp
ecti
vere
view
175
Trau
ma
pati
ents
who
und
erw
entR
SIat
tem
ptby
afl
ight
para
med
ic
N/
AN
/A
Ad
vers
eev
ents
asso
ciat
edw
ith
end
otra
chea
ltub
esw
ere
reco
rded
.
Jem
met
teta
l.20
0397
Pros
pect
ive
obse
rvat
iona
lstu
dy
109
Pati
ents
intu
bate
dby
grou
ndpa
ram
edic
sN
/A
N/
AE
ndot
rach
ealt
ube
plac
emen
twas
asse
ssed
onar
riva
latt
heho
spit
alby
anE
Dph
ysic
ian.
Jone
set
al.2
00498
Pros
pect
ive
obse
rvat
iona
lstu
dy
208
Ora
l:18
0N
asal
:28
Pati
ents
intu
bate
dby
grou
ndpa
ram
edic
sN
/A
N/
AE
ndot
rach
ealt
ube
plac
emen
twas
asse
ssed
onar
riva
latt
heho
spit
alby
anE
Dph
ysic
ian.
Mac
kay
etal
.200
199R
etro
spec
tive
revi
ew35
9A
lltr
aum
apa
tien
tsun
der
goin
gR
SIby
phys
icia
nsin
anai
rse
rvic
e
Em
erge
ncy
phys
icia
n-pe
rfor
med
RSI
Ane
sthe
siol
ogis
t-pe
rfor
med
RSI
End
otra
chea
ltub
esu
cces
sra
tes
and
vari
able
sre
late
dto
unsu
cces
sful
plac
emen
twer
ean
alyz
edan
dco
mpa
red
.N
ewto
net
al.2
00810
0R
etro
spec
tive
revi
ew17
5Tr
aum
apa
tien
tsw
hore
ceiv
edat
tem
pted
RSI
ina
helic
opte
rE
MS
serv
ice
bya
phys
icia
n
N/
AN
/A
Ad
vers
eev
ents
(hyp
oxem
iaan
dhy
pote
nsio
n)as
soci
ated
wit
hR
SIw
ere
reco
rded
.
Parw
anie
tal.
2007
101
Pros
pect
ive
obse
rvat
iona
lman
ikin
stud
y
53G
roun
dem
erge
ncy
para
med
ics
ata
trai
ning
sess
ion
N/
AN
/A
Mea
nen
dot
rach
ealt
ube
cuff
pres
sure
sw
ere
reco
rded
onm
anik
ins.
Prat
tand
Hir
schb
erg
2005
102
Pros
pect
ive
obse
rvat
iona
lstu
dy
32Pa
tien
ts>
15ye
ars
intu
bate
dby
grou
ndB
LS
EM
TsB
LS
EM
Tstr
aine
din
end
otra
chea
lin
tuba
tion
N/
AE
ndot
rach
ealt
ube
plac
emen
twas
asse
ssed
byan
ED
phys
icia
n.W
hen
none
was
esta
blis
hed
inth
efie
ld,
alte
rnat
eve
ntila
tion
met
hod
sw
ere
asse
ssed
.Sv
enso
net
al.2
00710
3R
etro
spec
tive
stud
y62
Ad
ultp
atie
nts
tran
spor
ted
byai
rpa
ram
edic
sor
phys
icia
nsN
/A
N/
AM
ean
end
otra
chea
ltub
ecu
ffpr
essu
res
wer
ere
cord
edat
the
rece
ivin
gfa
cilit
y.Ti
amfo
ok-M
orga
net
al.2
00610
4Pr
ospe
ctiv
eob
serv
atio
nals
tud
y17
0Pa
tien
tsw
ith
intu
bati
onat
tem
ptby
flig
htpa
ram
edic
sor
nurs
es
Polic
ytr
acki
ngSp
O2
whe
nin
tuba
ting
N/
AE
ndot
rach
ealt
ube
adve
rse
even
ts,
spec
ifica
llyd
esat
urat
ion,
wer
ere
cord
ed.
(Con
tinu
edon
next
page
)
31
Preh
osp
Em
erg
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cMas
ter
Uni
vers
ity o
n 11
/03/
14Fo
r pe
rson
al u
se o
nly.
TA
BL
E9.
The
me
7—Fi
eld
Intu
bati
on(n
=16
)(C
onti
nued
)
Cit
atio
nM
etho
dN
Popu
lati
onIn
terv
enti
onC
ontr
olO
utco
me
Wan
get
al.2
00910
5Pr
ospe
ctiv
eob
serv
atio
nals
tud
y1,
954
Pati
ents
inw
hom
intu
bati
onw
asat
tem
pted
bypa
ram
edic
s
N/
AN
/A
Ad
vers
eev
ents
and
mor
talit
yas
soci
ated
wit
hen
dot
rach
ealt
ubes
wer
ere
cord
ed.
Wan
get
al.2
00610
7Pr
ospe
ctiv
eob
serv
atio
nals
tud
y1,
953
Pati
ents
wit
hin
tuba
tion
atte
mpt
bygr
ound
orai
rpa
ram
edic
s(9
5%),
nurs
es,o
rph
ysic
ians
(5%
)
N/
AN
/A
Ad
vers
eev
ents
asso
ciat
edw
ith
end
otra
chea
ltub
esw
ere
reco
rded
.
Wan
get
al.2
00310
6Pr
ospe
ctiv
eob
serv
atio
nals
tud
y66
3/78
3Pa
tien
tsw
ith
intu
bati
onat
tem
ptby
grou
ndan
dai
rpa
ram
edic
s,nu
rses
,or
phys
icia
ns
N/
AN
/A
End
otra
chea
ltub
esu
cces
sra
tes
and
vari
able
sre
late
dto
unsu
cces
sful
plac
emen
twer
ean
alyz
ed.
Wan
get
al.2
00110
8R
etro
spec
tive
char
tre
view
592
Pati
ents
intu
bate
dby
grou
ndE
MS
para
med
ics
N/
AN
/A
End
otra
chea
ltub
epl
acem
entw
asas
sess
edon
arri
vala
tthe
hosp
ital
byan
ED
phys
icia
n.W
irtz
etal
.200
7109
Pros
pect
ive
obse
rvat
iona
lstu
dy
132
Pati
ents
intu
bate
dby
grou
ndE
MS
para
med
ics
N/
AN
/A
End
otra
chea
ltub
epl
acem
entw
asas
sess
edon
arri
vala
tthe
hosp
ital
byan
ED
phys
icia
n.
Pape
rsre
late
dto
pati
ents
afet
yan
dpr
ehos
pita
lint
ubat
ion
(n=
16).
BL
S=
basi
clif
esu
ppor
t;E
D=
emer
genc
yd
epar
tmen
t;E
MS
=em
erge
ncy
med
ical
serv
ices
;EM
T=
emer
genc
ym
edic
alte
chni
cian
;N/
A=
not
appl
icab
le;R
SI=
rapi
d-s
eque
nce
intu
bati
on;S
pO2
=sa
tura
tion
ofpe
riph
eral
oxyg
en.
32
Preh
osp
Em
erg
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cMas
ter
Uni
vers
ity o
n 11
/03/
14Fo
r pe
rson
al u
se o
nly.
Bigham et al. PATIENT SAFETY IN EMS SYSTEMATIC REVIEW 33
CONCLUSION
We systematically reviewed the literature to identify allpublished articles on the topic of patient safety in EMS.We identified seven themes within the literature: clini-cal judgment, adverse events and error reporting, com-munications, land vehicle safety, aircraft safety, inter-facility transport, and intubation. While this literaturereview yielded primarily descriptive research, it is ev-ident that rigorous and targeted research is needed toenable the translation of existing patient safety knowl-edge from other fields of medicine and to the genera-tion of new understanding of patient safety in the EMSsetting.
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Supplementary material available online
Appendix 1-Systematic Reviews Search Strategy
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