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What is What is E.V.E.N.T.E.V.E.N.T.??
• System to collect and utilize information from untoward events to help improve consistency and quality of EMS care
• Anonymous, non-punitive, confidential • Help identify needed changes in systems and
processes without placing blame on individual providers
• Modeled after Pennsylvania system
Who Developed Who Developed E.V.E.N.T.E.V.E.N.T.??• Center for Leadership, Innovation and Research in EMS• National Association of Emergency Medical Technicians• National EMS Management Assn• Emergency Medical Services Chiefs of Canada• National Association of State EMS Officials• North Central EMS Institute
How Does It Work?How Does It Work?
1. Provider submits report on event via EVENT website
2. Report reviewed by CLIR staff Ensure report meets criteria Identifying info removed (name, agency,
electronic signatures, URL components, etc.)
How Does It Work?How Does It Work?
3. Report sent to State EMS agency4. Events posted to Google Group
Enroll by emailing [email protected] Name, EMS agency or affiliation Notification within 48 hours Does NOT include State where incident occurred
How Does It Work?How Does It Work?
• Aggregate Reports– Compiled quarterly and annually– Sent to States– Distributed to site partners• Encouraged to send electronic copies to their members
– Posted on Google Groups– Posted on E.V.E.N.T. website– Email announcement sent to Google Group list
Who Can Submit a Report?Who Can Submit a Report?
• Any individual who encounters a problem or recognizes a situation in which a safety event occurred– EMS Providers (any level)– Supervisory personnel– Persons involved in care of patient post-EMS
What is a Reportable Event?What is a Reportable Event?
• Patient Safety Event• Near Miss Event• Line of Duty Death
Patient Safety EventPatient Safety Event
• Event/action leads to worsened patient outcome– System problems– Operations issues– Drug administration errors– Equipment failures or provider errors of omission
or misuse– Any clinical aspect of patient care
PatientPatientSafetySafetyEventEvent
Patient Safety Event ReportsPatient Safety Event Reports
• United States, December 2010 – Patient Died, ambulance response delayed
• United States, January 2011 – Morphine given instead of Diphenhydramine
• United States, July 2011 – Patient Harmed, Stretcher latch failed, stretcher and patient fell to ground
• United States, May 2012 – Patient Harmed, Succinylcholine given to pt rather than Cardizem due to expiration date label placed improperly
Near MissNear Miss
• An unplanned event that did not result in injury, illness, or damage, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage.
Near Near Miss Miss ReportReport
Near Miss ReportsNear Miss Reports
• United States, March 2011 – Near Miss, IO drill bit broke during procedure
• United States, February 2012 – Near Miss, IV tubing had port factory installed backward, oral version of medication administered instead
• United States, March 2012 – Near Miss, Large patient rolled on stretcher, tipping stretcher over
• United States, April 2012 – Near Miss, nurse reported child transported improperly restrained
Line of Duty Death RegistryLine of Duty Death Registry
• Designed by EMS practitioners to share information regarding line of duty deaths
• State EMS Director and National EMS Memorial Service are notified via email
RecallsRecalls
• Ambulance and EMS Equipment recall notices are sent to the State agency and posted on Google Groups and the E.V.E.N.T. website
Site PartnersSite PartnersNational
• ACEP• CAAHEP• CoAEMSP• CECBEMS• EMS Chiefs of Canada• NAEMD• NAEMT• NAEMSP
• NASEMSO• NEMSMA• NEMS Memorial Service• Nat’l Org of State
Offices of Rural Health• NREMT• NVFC
Site PartnersSite PartnersSTATE
• Iowa EMS Assn• New York State Vol. Amb. & Rescue Assn• North Dakota EMS Association• Oregon EMS Association• Pennsylvania Emergency Health Svcs. Council• South Carolina EMS Association
OTHER• Humboldt General Hospital EMS Rescue• North Central EMS Institute
Thank You!
