Perspectives on Safety
Safety in the Prehospital Emergency Medical Services Setting
Emergency medical services (EMS) in the United States is comprised of more than 20,000 agencies and over 800,000 workers.(1) Emergency medical technicians (EMTs) and paramedics provide care to those at their moment of greatest need, often with location and time constraints, responding to an estimated 17–28 million emergencies annually in the US.(2) Because of these features, EMS serves as the gateway into hospitals for millions with acute illness or injury and provides the initial care and safety net for public health emergencies.(3) Despite this key role, our understanding of patient and clinician safety in EMS is poor, with limited efforts to improve safety nationwide.
Emergency medical services care can occur anywhere—the roadside, in a home, or in public settings—with threats to safety that are unspecified, unpredictable, and/or uncontrollable. Many calls for EMS assistance involve critical or potentially critical injury or illness like trauma, altered sensorium, breathing difficulty, new neurologic dysfunction, or severe pain.(2) The EMS clinician must think, move, and react quickly to lessen threats to life and limb, and to quickly stabilize the patient. Delays, interruptions, or distractions are common and may contribute to error in judgment, medication choices and delivery, or in doing a procedure. Despite these potential yet known threats, the annual incidence of poor patient safety outcomes in EMS nationwide is unknown. The dearth of data and information on patient safety in the EMS setting is linked to the absence of an agreed-upon global database of EMS patient safety events, compounded by a lack of a reference criteria for the diagnosis of error or adverse events in EMS operations.(4)
Common threats to the safety of EMTs and paramedics are varied and include lifting and moving patients, shift work and overtime work, fatigue, and poor teamwork.(5,6) Musculoskeletal sprains or strains are the most common of injury in EMS workers (7), often linked to moving or lifting patients.(6) More insidious but pervasive are other threats based on work factors that include schedules, fatigue, and poor sleep. For example, long duration shifts (e.g., >12 hours) and overtime work hours are common.(8) More than half of EMTs and paramedics report poor sleep quality, severe fatigue at work, and inadequate recovery between scheduled shifts.(5,9) Odds of injury are 1.9 times greater (95% CI: 1.1, 3.3) among fatigued EMS clinicians than the nonfatigued.(10) The risk of injury is also high among EMS crews in which the teammates lack experience working together, which is common.(11)
The culture of EMS organizations plays an important role in safety. Organizational safety culture refers to the collective beliefs and perceptions of workers regarding the safety of their workplace operations.(12) Poor organizational safety culture is a threat relevant to both patients and clinicians in the EMS setting. Many EMTs and paramedics believe their agency's safety culture is poor.(13) Odds of poor safety outcomes for both patients and EMS clinicians are higher among EMS organizations with lower safety culture scores than organizations with higher scores.(14)
Many threats to patient and clinician safety are potentially modifiable with changes in policy, education, and training. For example, high-fidelity simulation-based training has been linked to improved performance with the low-frequency, high-risk clinical care events that occur in the EMS setting.(15) Most EMS education programs have the capacity to provide simulation-based training (16), but many EMTs and paramedics do not receive such training.(16) Greater emphasis on simulation as a core component of EMS education may improve safety for patients and clinicians.
Fatigue and poor sleep are widespread in EMS, with evidence linking fatigued EMS clinicians to poor safety outcomes.(17) Despite the dangers, many in EMS accept fatigue as "part of the job." The 2018 guideline for fatigue risk management in EMS offers a roadmap to address this threat (18), providing detailed instruction for leaders of EMS organizations who desire to develop fatigue risk management programs tailored to local needs.
The greatest opportunity will come by improving organizational safety culture.(14) The wide variation in perceptions of safety culture across operations point to a need to educate EMS administrators on the role and influence that safety culture has on safety and performance.(13) Emerging evidence shows that improving safety culture with multimodal interventions will make a positive impact on workers and outcomes.(19) Targeting teamwork and promoting better team behavior and interaction may be the greatest point of leverage.(19) This need to improve teamwork and team interaction is noteworthy because EMS care is inherently a team-based model of care delivery, most often delivered in dyads.(20) At present, relatively little planning goes into EMS dyad configuration. An EMT or paramedic will have, on average, 19 different partners in one year and work only one-third of his/her shifts with his/her most frequent partner.(20) The risk of injury is greatest among EMS partnerships working just one shift together.(11) Partnerships with 4 to 9 shifts working together are 75% less likely to experience a work-related injury than are partnerships with just one shift of prior work.(11) Poor familiarity among partners may have a negative impact on select team behaviors.(20,21)
Emergency medical services are a critical part of health care but they are subject to many safety threats. We think that addressing the opportunities noted above, starting with a new emphasis on local organizational safety culture coupled with governmental action, will allow for better care and better outcomes—for patients and EMS workers. Three examples of governmental action include (i) the 2018 evidence-based guidelines for fatigue risk management in EMS (18); (ii) the Strategy for a National EMS Culture of Safety (22); and (iii) the EMS Provider and Patient Safety in Ambulances project.(23) While these projects and programs will help improve safety, additional action is needed, beginning with research that identifies and quantifies threats to safety.
P. Daniel Patterson, PhD Associate Professor Department of Emergency Medicine University of Pittsburgh Pittsburgh, PA
Donald M. Yealy, MD Professor (tenured) and Chair of Emergency Medicine Professor of Medicine and Clinical and Translational Sciences University of Pittsburgh School of Medicine Pittsburgh, PA
1. Mears G, Armstrong B, Fernandez AR, et al. 2011 National EMS Assessment. US Department of Transportation, National Highway Traffic Safety, Administration, Federal Interagency Committee on Emergency Medical Services, Washington, DC; 2012. [Available at]
5. Patterson PD, Weaver MD, Hostler D. EMS provider wellness. In: Cone DC, Brice JH, Delbridge TR, Myers JB, eds. Emergency Medical Services: Clinical Practice and Systems Oversight. Vol 2. Chichester, West Sussex: John Wiley & Sons, Inc.; 2015:211-216. ISBN: 9781118865309.
6. Patterson PD, Weaver MD, Hostler D. Occupational injury prevention and management. In: Cone DC, Brice JH, Delbridge TR, Myers JB, eds. Emergency Medical Services: Clinical Practice and Systems Oversight. Vol 2. Chichester, West Sussex: John Wiley & Sons, Inc.; 2015:217-221. ISBN: 9781118865309.
8. Patterson PD, Runyon MS, Higgins JS, et al. Shorter versus longer shift duration to mitigate fatigue and fatigue-related risks in Emergency Medical Services personnel and related shift workers: a systematic review. Prehosp Emerg Care. 2018;22(suppl 1):28-36. [go to PubMed]
19. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-374. [go to PubMed]
22. Braithwaite S, Murray R, Elmes P, et al. Strategy for a National EMS Culture of Safety. Washington, DC: National Highway Traffic Safety Administration, Health Resources and Services Administration, EMS for Children Program, American College of Emergency Physicians; 2013. [Available at]