The Association EMS and Safety Outcomes

THE ASSOCIATION BETWEEN EMS WORKPLACE SAFETY CULTURE AND SAFETY

OUTCOMES

Matthew D. Weaver, MPH, NREMT-P, Henry E. Wang, MD, MS, Rollin J. Fairbanks, MD, MS,P. Daniel Patterson, PhD, EMT-B

ABSTRACT

Background. Prior studies have highlighted wide varia-tion in emergency medical services (EMS) workplace safetyculture across agencies. Objective. To determine the asso-ciation between EMS workplace safety culture scores andpatient or provider safety outcomes. Methods. We admin-istered a cross-sectional survey to EMS workers affiliatedwith a convenience sample of agencies. We recruited theseagencies from a national EMS management organization. Weused the EMS Safety Attitudes Questionnaire (EMS-SAQ) tomeasure workplace safety culture and the EMS Safety In-ventory (EMS-SI), a tool developed to capture self-reportedsafety outcomes from EMS workers. The EMS-SAQ pro-vides reliable and valid measures of six domains: safetyclimate, teamwork climate, perceptions of management,working conditions, stress recognition, and job satisfaction.A panel of medical directors, emergency medical techni-cians and paramedics, and occupational epidemiologistsdeveloped the EMS-SI to measure self-reported injury, med-ical errors and adverse events, and safety-compromising be-haviors. We used hierarchical linear models to evaluate theassociation between EMS-SAQ scores and EMS-SI safety out-come measures. Results. Sixteen percent of all respondentsreported experiencing an injury in the past three months,four of every 10 respondents reported an error or adverseevent (AE), and 89% reported safety-compromising behav-iors. Respondents reporting injury scored lower on five ofthe six domains of safety culture. Respondents reporting anerror or AE scored lower for four of the six domains, whilerespondents reporting safety-compromising behavior had

Received April 28, 2011, from the Department of EmergencyMedicine, University of Pittsburgh (MDW, DJP), Pittsburgh, Penn-sylvania; the Department of Emergency Medicine, University of Al-abama at Birmingham (HEW), Birmingham, Alabama; and the Na-tional Center for Human Factors Engineering in Healthcare (RJF),Washington, DC. Revision received July 5, 2011; accepted for publi-cation July 25, 2011.

The project described was supported by Award Number KL2RR024154 from the National Center for Research Resources. The con-tent is solely the responsibility of the authors and does not necessar-ily represent the official views of the National Center for ResearchResources or the National Institutes of Health. Additional grant sup-port was provided by the North Central EMS Institute (NCEMSI)and Pittsburgh Emergency Medicine Foundation (PEMF).

Address correspondence and reprint requests to: Daniel Patterson,PhD, University of Pittsburgh, Emergency Medicine, 230 McKeePlace, Suite 400, Pittsburgh, PA 15213. e-mail: [email protected]

doi: 10.3109/10903127.2011.614048

lower safety culture scores for five of the six domains. Con-clusions. Individual EMS worker perceptions of workplacesafety culture are associated with composite measures of pa-tient and provider safety outcomes. This study is preliminaryevidence of the association between safety culture and pa-tient or provider safety outcomes. Key words: safety; EMT;injury; error; workplace; outcomes

PREHOSPITAL EMERGENCY CARE 2012;16:43–52

INTRODUCTION

Safety culture refers to the shared perceptions or atti-tudes of a work group toward safety.1 Leading author-ities support regular safety culture assessments as partof health care organizational quality assurance.2 Priorstudies of the in-hospital setting have linked safetyculture scores to negative patient outcomes (more fre-quent medication errors, increased length of stay),provider outcomes (increased injury), and compositemeasures of safety outcomes.3–6 In high-risk occupa-tions outside of health care, safety culture scores havebeen linked to occupational injuries, accidents, andsafety audit measures.7–9

There is reason to believe that workplace safetyculture impacts clinical and operational practices inemergency medical services (EMS). Using structuredinstruments, prior studies have identified wide varia-tion in EMS workplace safety culture.10,11 For example,air medical agencies scored higher than ground EMSagencies across all domains of safety culture.11 Lowersafety culture scores were associated with higher an-nual call volume.11 However, no studies have associ-ated workplace safety culture with patient or provideradverse events (AEs).

The objective of this study was to determine the as-sociation between EMS workplace safety culture andpatient or provider safety outcomes.

METHODS

Study Design and Sampling

We used a cross-sectional study design of a conve-nience sample of EMS workers. As an initial step,we sought to secure study participation from EMSagency–level leaders prior to surveying individualEMS workers. We approached the National EMSManagement Association (NEMSMA) and requesteduse of their member e-mail Listserv to recruit EMS

43

44 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2012 VOLUME 16 / NUMBER 1

agency leaders. We distributed a standard letter to theNEMSMA e-mail Listserv three times over an eight-week recruitment period. The NEMSMA is an all-inclusive professional association of 2,253 EMS lead-ers, managers, and administrators committed to bestpractices in EMS. A full description of NEMSMAmember characteristics is not possible because of a lackof data maintained by the association. Twenty-sevenagencies responded to our letter and completed theenrollment procedure. Most of these 27 agencies werelocated in the Northeast and Midwest U.S. Census re-gions (n = 20, 74%), were self-described third-servicemodels (n = 17, 63%), were a private nonprofit own-ership delivery model (n = 16, 59%), and employedbetween 21 and 100 employees (n = 20, 74%). The Uni-versity of Pittsburgh Institutional Review Board ap-proved this study.

Instruments

Measurement of Safety Culture

We measured EMS safety using the EMS Safety At-titudes Questionnaire (EMS-SAQ). The EMS-SAQ isa 60-item survey that collects information on respon-dents’ opinions regarding perceptions of safety cultureof an organization.10,11 The EMS-SAQ includes 30 corequestions that measure six domains of safety culture:safety climate, teamwork climate, perceptions of man-agement, working conditions, stress recognition, andjob satisfaction. Responses to EMS-SAQ items are cap-tured on a five-point Likert scale and weighted from0 to 100 (disagree strongly = 0, disagree slightly =25, neutral = 50, agree slightly = 75, agree strongly =100).10–12 Standard scoring for the EMS-SAQ includescalculating a domain mean score and percentage pos-itive of responses.10–12 We originally developed theEMS-SAQ by adapting the previously validated In-tensive Care Unit Safety Attitudes Questionnaire (theICU-SAQ).10−12 Prior studies involving both the EMS-SAQ and the ICU-SAQ have demonstrated the toolsto have positive psychometric properties of reliabilityand construct validity.

Measurement of Safety Outcomes

There are few tools for identifying EMS AEs. Uniformcriteria for identifying and rating safety outcomes inEMS do not exist, while standards for commonly heldEMS data sources (i.e., the EMS patient care report)remain under development.13 While frequently usedfor safety research, electronic patient care reports areoften incomplete and inaccurate.14–16 Self-reporting isa widely used and cost-efficient alternative to otherforms of AE detection.17,18

We identified EMS provider and patient safetyevents using the EMS Safety Inventory (EMS-SI). The

EMS-SI is a 44-item survey developed by a panel ofEMS medical directors, emergency medical technicians(EMTs) and paramedics, and occupational epidemiolo-gists to identify events or behaviors with harm or riskof harm. We developed the EMS-SI using a modifiedDelphi process. After identifying candidate items froma literature review, a panel of experts (medical direc-tor physicians, prehospital providers, prehospital edu-cators, and epidemiologists) identified items pertinentto provider or patient safety. We instructed the panelto use the Agency for Healthcare Research and Qual-ity (AHRQ) Patient Safety Indicator tool as a guideto classify EMS-SI items into one of three compos-ite safety outcome measures: 1) provider injury (twoitems; e.g., “I was injured during a shift”), 2) patientcare error or AE (25 items; e.g., “I accidently dislodgedan ET tube”), and 3) safety-compromising behaviors(17 items; e.g., “I have greatly exceeded the speed limitwhile responding lights and sirens”) (Appendix 1). Thetime period of reference for the outcome measures wasthe previous three months.

We used two nominal, seven-option, categoricalscales to elicit responses to EMS-SI items. Response op-tions for each scale are detailed in Appendix 1. Our ex-pert panel considered “probably yes” and “definitelyyes” as indicators of a negative safety outcome (i.e., anaffirmative response). The second nominal scale wasused on a subset of 19 items assigned to the error or AEcomposite outcome measure. The expert panel consid-ered “ran out of time,” “forgot to perform,” and “didnot think it was necessary” as indicators of a negativesafety outcome.

Study Protocol

Agency contacts provided key information on eligi-ble respondents prior to survey dissemination. Key in-formation included e-mail address, certification level(EMT-Basic or paramedic), full-time status (full-time,part-time, or volunteer), years of agency experience(e.g., five years), and percentage of total work devotedto clinical duties for all EMTs and paramedics (e.g.,75%). Agency contacts were instructed to consider allemployees who worked clinically for the agency to beeligible, and for administrative personnel and nonclin-ical workers to be ineligible.

From January to June 2010, agency contacts dis-tributed the survey to eligible EMTs and paramedicsusing our survey system. The system sent a standarde-mail message with a secure link to the survey. Thise-mail message included an opt-out option (a securelink) that, when clicked, documented the individual’se-mail address as opting out of all future e-mail mes-sages from the survey system. We designed the sur-vey system to provide agency contacts the ability toclick a button that would resend the survey e-mailmessage and links to the survey and opt-out option to

Weaver et al. SAFETY CULTURE AND SAFETY OUTCOMES 45

nonrespondents. These e-mail messages were not sentto individuals who had previously selected to opt out.The survey system stored all survey data on a se-cure server and assigned each completed survey a ran-domly generated survey identification (ID) numberand unique agency ID number.

Analysis of Data

We used a respondent-level analysis and calculatedfrequencies, percentages, means, and corresponding95% confidence intervals for the EMS-SAQ and EMS-SI composite safety measures. We used Rao-Scott chi-square tests and analysis of variance (ANOVA) to ex-amine associations between respondent characteris-tics, EMS-SAQ scores, and EMS-SI composite safetymeasures. We used hierarchical linear models to eval-uate the association between EMS-SAQ domain scoresand EMS-SI composite safety outcome measures, whileaccounting for within-agency clustering of respon-dents. We report the domain mean score and corre-sponding 95% confidence intervals for each EMS-SAQdomain stratified by the EMS-SI composite safety mea-sure.

RESULTS

Twenty-seven agencies participated in the study. Sixagencies failed to fulfill the study protocol within thesix-month study period (completed the demographicinformation but did not send surveys to agency per-sonnel), leaving responses from 21 agencies for analy-sis. We received 416 completed surveys (mean agencyresponse rate of 42.1%; range 5.3% to 81.3%).

Sample Demographics

Three-fourths of the participating agencies were lo-cated in either the Midwest (38.1%) or the Northeast(42.9%) census regions. Half (52%) operated as a third-service model and reported funding from local munic-ipalities as a public service affiliate (Table 1). The pri-vate, nonprofit financial model was the most commontype of ownership (71.4%). Half of participating agen-cies employed between 51 and 100 personnel (Table 1).

Most respondents were white (90.6%), were male(69.2%), were between 26 and 35 years old (36.1%),and reported some college education (44.2%). Halfwere certified at the EMT-Paramedic (paramedic) level(51.2%; Table 2). Sixty percent of the respondents re-ported ≥10 years of total EMS experience. Nearly halfreported >5 years of experience at the agency wherethey are currently employed (47.4%; Table 2).

The aggregated SAQ domain mean scores were asfollows: safety climate 72.2 (67.0–77.5), teamwork cli-mate 70.1 (63.9–76.2), perceptions of management 69.6(62.9–76.2), working conditions 66.0 (58.5–73.6), stressrecognition 54.3 (51.9–56.7), and job satisfaction 75.8(69.7–81.9) (Table 3).

Injury

One-sixth of all respondents reported having experi-enced an injury in the previous three months (16%;Table 2). The reporting of injury was associated withprovider age category (p < 0.05). The mean domainscores for safety climate, teamwork climate, percep-tions of management, working conditions, and job sat-isfaction were lower among the respondents report-ing injury than among those who did not (p < 0.05)(Table 3).

Medical Error and Adverse Events

Four out of every 10 respondents recorded an affirma-tive response for EMS-SI items measuring error or AE(42%; Table 2). Reporting of an error or AE was as-sociated with provider age category and certificationlevel (p < 0.05). The mean domain scores for safety cli-mate, teamwork climate, perceptions of management,and working conditions were lower among the respon-dents with an affirmative response for an error or AEthan among the respondents without an error or AE(p < 0.05) (Table 3). The mean score for stress recog-nition was four points higher among the respondentsindicating an error or AE than among their respectivereference group (p < 0.05).

Safety-Compromising Behaviors

Nine of every 10 respondents reported safety-compromising behaviors (89%; Table 2). The reporting

TABLE 1. Demographic Characteristics of the ParticipatingAgencies

n (%)

Census regionMidwest 8(38.1%)Northeast 9(42.9%)West 2(9.5%)South 2(9.5%)

ClassificationThird-service/government 11(52.4%)Hospital-based 6(28.6%)Fire-based 1(4.8%)Rescue squad 2(9.5%)Other 1(4.8%)

OwnershipPrivate for-profit 2(9.5%)Private nonprofit 15(71.4%)Government-funded 2(9.5%)Member-supported 1(4.8%)Other 1(4.8%)

Number of employees1–20 employees 1(4.8%)21–50 employees 6(28.6%)51–100 employees 10(47.6%)101–400 employees 4(19.0%)

Annual call volume<5,000 dispatches 8(38.1%)5,000–15,000 dispatches 7(33.3%)15,001–30,000 dispatches 4(19.0%)>30,000 dispatches 2(9.5%)

TOTAL 21(100%)

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197

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68.4

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68.1

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62.6

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56.7

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Em

ploy

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tsta

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∗†

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46


TABLE 3. Hierarchical Linear Modeling of Safety Culture Domain Mean Scores (95% Confidence Interval) across OutcomeCategories with Adjustment for Agency Clustering

Safety Climate Teamwork ClimatePerceptions ofManagement Working Conditions Stress Recognition Job Satisfaction

Injury ∗ † † † †Yes 63.9

(57.0–70.8)60.6 (53.7–67.4) 56.1 (47.8–64.3) 54.5 (46.7–62.4) 54.9 (50.9–59.0) 65.0 (58.4–71.6)

No 73.8(68.8–78.8)

71.9 (66.0–77.8) 72.1 (66.0–78.3) 68.2 (60.8–75.6) 54.1 (51.6–56.7) 77.8 (71.9–83.7)

Medical error or adverseevent

∗ ∗ ∗ ∗ ∗

Yes 68.2(63.5–73.0)

66.5 (61.4–71.7) 66.8 (60.9–72.6) 62.3 (54.8–69.8) 56.6 (53.8–59.4) 72.5 (66.9–78.1)

No 75.1(69.1–81.1)

72.6 (65.3–79.9) 71.6 (64.0–79.2) 68.7 (60.1–77.3) 52.6 (49.4–55.8) 78.1 (70.8–85.5)

Feelings ofcompromisedpersonal or patientsafety

∗ ∗ ∗ ∗ ∗

Yes 71.3(65.6–77.0)

68.8 (62.3–75.4) 68.1 (61.0–75.2) 64.4 (56.5–72.4) 55.1 (52.6–57.6) 74.5 (67.9–81.1)

No 79.7(74.1–85.3)

79.7 (74.2–85.2) 81.3 (75.0–87.5) 78.5 (71.2–85.7) 48.0 (39.7–56.3) 85.9 (81.1–90.6)

∗p < 0.05.†p < 0.0001.

of these behaviors was associated with provider agecategory and employment status (p < 0.05). The meandomain scores for safety climate, teamwork climate,perceptions of management, working conditions, andjob satisfaction were lower among the respondents in-dicating safety-compromising behaviors than amongthe respondents who denied such behaviors (p < 0.05)(Table 3).

DISCUSSION

This study provides preliminary evidence of an asso-ciation between safety culture scores and safety out-comes in the EMS setting. In this study sample, weidentified strong associations between five of the sixdomains of EMS workplace safety culture and thethree composite measures of patient and providersafety outcomes. If independently validated, our find-ings have profound implications for EMS.

Prior studies have observed similar associations be-tween workplace safety culture and health care out-comes. For example, a multicenter study of intensivecare units linked higher rates of error to lower safetyculture scores.4 Another study of 91 hospitals linkedlower safety climate scores to a higher annual rate ofa negative patient safety indicators adopted by theAHRQ.3 Although our research does not determinecausality, it is an important finding because it suggeststhat EMS-SAQ safety culture survey scores can be usedas a proxy measure for AE rates in individual EMS or-ganizations.

We determined that the frequency of reported safetyoutcomes by paramedics exceeded the frequency ofevents reported by EMTs. There are several possible

explanations for this difference. Paramedics providea broader range of clinical care and interventions, in-cluding invasive procedures and medication adminis-tration, which would seem to create opportunity formore frequent negative outcomes. These individualsmay be more apt to engage in risk-taking behaviors.19

It is also possible that as a group paramedics are morecomfortable reporting errors and AEs, which wouldcreate a reporting bias. A substantial number of EMS-SI items query respondents on behaviors, actions, andprocedures that are potentially more common amongparamedics in most regions (e.g., “I did not perform a12-lead ECG on a patient with chest pain”).

Our approach to identifying outcomes was conser-vative. We classified a respondent’s “affirmative” re-sponse to any one item of a composite outcome to-wards the count of that outcome. Future revisions tothe EMS-SI tool should encompass level-specific sur-veys. Employing a score of harm or severity to EMS-SIitems may help investigators and EMS officials sepa-rate the severe from minor, further improving outcomeidentification.

A large body of safety research over the past 20years has emphasized the importance of systems andorganizational factors as predictors of poor or posi-tive safety outcomes.20–22 James Reason’s Swiss cheesemodel of an accident is a widely recognized illustrationof this concept.23 The climate or culture of an organi-zation may be viewed as a slice of cheese positionedfarthest away from the negative event/accident. Sev-eral studies have established a relationship betweensafety culture scores and worker injury or patientsafety outcomes. There are numerous threats to EMSworker and patient safety. For example, patients are


often violent, providers often deviate from protocol,partnerships are inconsistent and threaten teamwork,and injury rates among EMS workers exceed that of thegeneral working public.24–32 The magnitude of eachthreat is poorly understood by the EMS industry be-cause of a lack of adequate and standardized docu-mentation of patient and provider safety events.33,34

In this study, we report an association between EMSworkplace safety culture scores and safety outcomemeasures of injury, error, and AEs. Our findings areearly evidence that the EMS-SAQ is a valid indica-tor of EMS agency safety conditions. Lack of a sta-tistically significant difference in safety outcomes andEMS-SAQ domain scores across demographic stra-tums is a worthy line of inquiry that deserves furtherexploration. These findings, while preliminary, suggestthat the EMS work environment is associated with thesafety of patients and providers.

LIMITATIONS AND FUTURE RESEARCH

Our mean agency response rate (42.1%) is similar tothat of previous studies of health care workers andsafety culture studies, including prior studies of EMSagencies.35–40 Our analyses focused on the associa-tion between EMS-SAQ domain scores and EMS-SIcomposite outcomes at the individual EMS workerlevel. We did not analyze and interpret our findingsfrom the agency perspective with the intent of com-paring findings across agencies. However, we recog-nize that inclusion of data from low-response agen-cies may introduce concern for the external validityof our data. One concern may be that EMS work-ers from agencies with low response rates may notrepresent workplace safety culture in their agency asa whole and possibly provide an overrepresentationof negative safety outcomes statistics. We examinedour data from the agency level perspective and deter-mined that domain mean scores for five of six EMS-SAQ domains were lower among respondents fromagencies with low response rates (<60%) than agen-cies with higher response rates (≥60%). We deter-mined that EMS workers from agencies with ≥60%agency-level response rates had higher mean domainscores than workers from agencies with <60% re-sponse rates for all domains except stress recogni-tion. These differences are as follows: safety climate–12.9 (p = 0.003), teamwork climate –12.0 (p = 0.019),perceptions of management –16.8 (p = 0.008), work-ing conditions –19 (p = 0.002), and job satisfaction–12.8 (p = 0.011). We then determined that the cu-mulative frequency of EMS-SI composite outcomesfindings were not statistically different when strat-ified by low versus high agency response rate: in-jury = 14.4% in high-response agencies versus 19.2%in low-response agencies (p = 0.5619); error andAE = 40.0% in high-response agencies versus 41.7%

in low-response agencies (p = 0.9341); and safety-compromising behaviors = 85.6% in high-responseagencies versus 88.6% in low–response agencies (p =0.3603).

Our findings may have limited generalizability toEMS workers from certain types of EMS deliverymodels (e.g., fire-based models). Part-time employ-ees and volunteers are more common among non-respondents, suggesting possible limited generaliz-ability to these EMS workers. Perceptions of oneor more domain of EMS-SAQ may be positivelyor negatively impacted if more part-time individu-als responded. Additional research focused on part-time EMS workers would address this concern andshed light on the magnitude of possible differencesin findings across employment status. Table 4 high-lights observable similarities between our study sam-ple and samples of workers from other multisite stud-ies. We believe these similarities provide an impor-tant frame of reference when interpreting our find-ings.

The EMS-SI tool provides insights into EMS globalsafety—not individual safety events. We chose thismethod because event-level detection is difficult, in-tensive, and expensive, and yields information on onlyselect events. Since our objective was to gauge over-all safety rather than specific processes of care, theuse of a composite measure of safety was appropriate.To ensure a robust and face-valid measure of safetyoutcomes, we used a modified Delphi consensus ap-proach with a panel of medical directors, epidemiol-ogists, and EMS workers to develop a unique self-reporting tool.41,42 The response options attached toeach EMS-SI item were developed by our panel anddesignated appropriate. A panel composed of differ-ent individuals might have rendered a different tooland different options for item response, and ultimatelyhave led to different findings in this study. The EMS-SItool is unique but comparable to a patient safety in-dicator tool developed by AHRQ and tested in priorlarge-scale safety culture studies.3 We continue to editand improve the EMS-SI.

The self-report nature of our safety outcome mea-sures is a strength and a weakness. We adopted athree-month period of recall, in recognition that occu-pational epidemiologists consider the accuracy of re-call to diminish beyond two months.43,44 We acknowl-edge that prior research has documented that EMTsunderreport medical errors and AEs at an estimatedrate of 4%.27,33,34 There is additional evidence that be-tween 11% and 32% of occupational injuries and acci-dents are not reported.7,45 Underreporting may be at-tributed to an unwillingness to report, particularly inagencies where a poor safety culture creates a fear ofretribution.46 Many EMS personnel may also fail to re-alize that an event has occurred, evidenced by a studyon the procedure of synchronized cardioversion.47


TABLE 4. Characteristics of the Study Sample Compared with Other Research Studies of EMS Workers

Study Sample

Characteristic Respondents NonrespondentsLEADS

Sample48

HighResponse

EMSSample10

NHTSAWorkforce

Report†

ResuscitationOutcomes

ConsortiumAgencies49

LongitudinalStudy of EMS

Turnover50

NationalSurvey of EMS

Safety Culture11

Individual characteristicsGender

Male 69.2% — 72.9% 71.8% 71–77% — — 73.2%Female 30.8% — 27.1% 28.2% 23–29% — — 26.8%

Certification∗EMT-Basic 34.1% 28.4% 58.1% 50.7% 72%‡ 58.2% — 19.4%Paramedic 51.2% 42.4% 34.6% 49.3% 22%‡ 34.2% — 62.1%Age—mean,

years36.6 — — — 35 — — —

RaceWhite 90.6% — — — 75-81% — — —Nonwhite 1.9% — — — 19-25% — — —

Employment status∗Full-time 69.5% 53.9% — — 89%§ — — 77.6%Part-time 18.0% 34.2% — — 11% § — — 20.6%Volunteer 12.5% 11.9% — — — — 1.8%

Agency affiliation (EMT unit of measurement)Fire-based 2.1% 4.7% 34.1% — +Includes

county/third— — —

County/third-service

51.7% 57.3% 12.1% — +30%¶ — — —

Hospital-based 28.4% 27.3% 9.9% — 20%¶ — — —Other 17.8% 10.6% 43.8% — 50%¶ — — —

Years of service at current agency<2 years 20.4% 22.0% — — — — — —2–4 years 32.2% 34.6% — — — — — —≥5 years 47.4% 43.4% — — — — — —Mean% clinical

work52.3% 61.4% — — — — — —

Agency characteristicsAgency affiliation

Fire-based 4.8% — — — — 62.5% 10.0% 11.5%County/third-service

52.4% — — — — 25.7% 22.5% 19.7%

Hospital-based 28.6% — — — — N/A 27.5% 29.5%Other 14.3% — — — — 11.8% 40.0% 39.3%

∗Indicates difference between the respondents and the nonrespondents in our study sample (p < 0.05).†The NHTSA workforce report includes statistics based on data from the 2003 and 2005 Current Population Survey (CPS), the 2007 National Registry of EMTs(NREMT) registration database, and the 2004–2005 Edition of the Bureau of Labor Statistics Occupational Outlook Handbook.‡Indicates that the source was the 2007 NREMT database statistics cited within the NHTSA Workforce report and excludes statistics from EMT-Intermediates.§Used to indicate that data from this source do not stratify EMTs by volunteer status and automatically labels an EMT as full-time based on the EMT’s working 35hours or more per week.¶Categories reported in the NHTSA Workforce report are not completely analogous to the stratums defined in this study. We collapsed several categories in theNHTSA Workforce report deemed similar to stratums in this study (e.g., 50% Other includes “private ambulance services” and “other” in the Workforce report; and30% County/third-service includes all types of local government affiliations).EMS = emergency medical services; EMT = emergency medical technician; LEADS = Longitudinal Emergency Medical Technician Attribute and DemographicStudy; N/A = not applicable; NHTSA = National Highway Traffic Safety Administration.

We used a cross-sectional study design, which can-not determine causality or determine whether poorsafety culture scores preceded or were the result ofnegative safety outcomes. We believe our findings donot highlight the true strength of association betweensafety culture and safety outcomes. Our findings pro-vide preliminary evidence that in one subset of theEMS population, safety culture is an important “meterof safety.” What is or is not a clinically meaningful dif-ference in safety culture scores across the injured ver-sus uninjured, for example, must be addressed. Find-ings from the current study provide the data requiredto design future research whereby investigators may

wish to test hypotheses and detect clinically meaning-ful differences in safety climate scores across stratumsof safety outcomes.

CONCLUSIONS

In this study, we detected associations between indi-vidual EMS worker perceptions of workplace safetyculture scores and composite measures of patient andprovider safety outcomes. This study is preliminaryevidence of the association between safety culture andpatient or provider safety outcomes.


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APPENDIX 1The EMS Safety Inventory

QuestionNumber Item Scale Category

1 . . ..I was injured during a shift. A Injury4 . . .I received a needle stick injury. A Injury11 . . .I did not establish an IV after two attempts because. . . B Error or AE12 . . . I did not use a secondary treatment device when the preferred failed (e.g., IO instead of IV

access, King airway instead of ET tube) because. . .

B Error or AE

13 . . .I did not check a glucose level in a patient with altered mental status because. . . B Error or AE14 . . ..I did not check a glucose level in a diabetic patient with nausea and vomiting because. . . B Error or AE15 . . .I did not perform an airway intervention (e.g., BVM, intubation, King/Combitube) on a

patient with congestive heart failure while en route to the hospital because. . .B Error or AE

16 . . .I did not intubate a patient in respiratory arrest because. . . B Error or AE17 . . .I did not place a patient on the monitor because. . . B Error or AE18 . . .I did not perform a 12-lead EKG on a patient with chest pain because. . . B Error or AE19 . . .I did not perform a 12-lead EKG on a patient with STEMI because. . . B Error or AE20 . . .I confirmed a STEMI but did not administer aspirin when warranted because. . . B Error or AE21 . . .I administered the wrong medication by not checking the label because. . . B Error or AE22 . . .I administered the wrong dose of medication by not confirming the dose because. . . B Error or AE23 . . .I transferred a patient at the emergency department (ED) with an unrecognized

esophageal intubation (ET tube placed in esophagus rather than trachea) because. . .

B Error or AE

24 . . .I did not secure an embedded object in a wound instead of securing the object withbandages and accidently removed it because. . .

B Error or AE

25 . . .I did not print and properly interpret a 6 inch EKG strip because. . . B Error or AE26 . . .I did not properly size a piece of equipment and then used it on a patient (e.g., ET tube,

C-collar, airway adjunct, IV catheter) because. . .B Error or AE

27 . . ..I did not transport a specialty care patient to a specialty care facility (i.e., trauma, stroke,pediatric) because. . .

B Error or AE

28 . . .I accidentally started an IO in a location outside of protocol. A Error or AE29 . . .I made a patient with chest pain ambulate instead of using a stretcher. A Error or AE30 . . .I did not administer the necessary treatment for a specific condition/malady. A Error or AE31 . . .I placed an IV into an artery instead of into a vein. A Error or AE32 . . .I accessed a dialysis port or other vascular device outside of protocol. A Error or AE33 . . .I accidentally dislodged an ET tube. A Error or AE34 . . .I accidentally dropped a patient while on a transportation device (i.e., stretcher, stair chair). A Error or AE35 . . .I accidentally caused physical injury to a patient moving the patient. A Error or AE2 . . .I was overly stressed during a shift. A Safety-compromising

behavior3 . . .I found myself at an unsafe scene. A Safety-compromising

behavior5 . . .I may have been contaminated with copious amounts of patient bodily fluids. A Safety-compromising

behavior6 . . .I was involved in a collision involving one of my agency’s vehicles. A Safety-compromising

behavior7 . . .I have reported for my shift without getting adequate rest beforehand. A Safety-compromising

behavior8 . . .I have reported for my shift after drinking alcohol within the previous 8 hours. A Safety-compromising

behavior9 . . ..I did not complete a pre-shift check of equipment and medications because. . . B Safety-compromising

behavior10 . . .I did not restock the ambulance before a call or shift because. . . B Safety-compromising

behavior36 . . .I have “fudged” information on a patient care report (i.e., vitals, chronology of events). A Safety-compromising

behavior37 . . .I felt vulnerable to harm due to lack of appropriate PPE (i.e., BSI, turnout gear, etc.). A Safety-compromising

behavior(Continued on next page)


QuestionNumber Item Scale Category

38 . . .I felt that a patient’s safety was jeopardized because my agency did not provide me withupdated equipment.

A Safety-compromisingbehavior

39 . . .I felt that my safety was jeopardized because my agency did not provide me with updatedequipment.


40 . . .I felt that a patient’s safety was jeopardized because my agency did not provide me withupdated protocols/policies/procedures.


41 . . .I felt that my safety was jeopardized because my agency did not provide me with updatedprotocols/policies/procedures.


42 . . .I have exceeded the speed limit while routinely driving the unit in a non-emergency mode. A Safety-compromisingbehavior

43 . . .I have greatly exceeded the speed limit while responding lights and sirens (i.e., more than15 mph over the posted speed limit).


44 . . .My “chute time” (time from call received to rolling) was greater than 1 minute. A Safety-compromisingbehavior

Scale Response Negative Safety Outcome

A Definitely notProbably notI’m not sureProbably yes YesDefinitely yes YesDo not wish to answerNot applicable to me

B Ran out of time YesForgot to perform YesNot part of protocolDid not think it was necessary YesContraindicatedDo not wish to answerNot applicable to me

AE = adverse event; BSI = body substance isolation; BVM = bag–valve–mask; EKG = electrocardiogram; EMS = emergency medical services; ET = endotracheal;IO = intraosseous (device); IV = intravenous (line); PPE = personal protective equipment; STEMI = ST-segment elevation myocardial infarction.

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Documents

The Association EMS and Safety Outcomes