Advancing paramedicine: Error,accountability and patient safety

Abstract

The consequences of human error range from the benign to the catastrophic. Feedback and formal review of failures in human performance are essential for learning and avoidance of harm in the future. However, anecdotal evidence suggests that paramedicine may sustain a culture where formal review of error may be considered punitive, hampering enhancements in care and professional maturity. With enhanced transparency of adverse events, mature review processes and acceptance and translation of recommendations, we look to a shift in the culture. Clinicians and organisations must be accountable for their role in review and audit of near misses and adverse events. There is a path forward for paramedicine, where courageous individuals are empowered to identify clinical error and speak up, promoting growth. We must prevent individual feelings of shame and fear of consequences. Only then can we see a true patient-centric safety culture in paramedicine, one which supports clinicians’ development.

Introduction

Whilst paramedicine has existed in some form since mediaeval times when the Knights Hospitaller roamed Jerusalem, the inevitability of human error has been around for much longer and is a major contributor to morbidity and mortality in healthcare. ¹ The consequences of human error range from the benign to the catastrophic, thus feedback and formal review of failures in human performance are essential for learning and mitigation or avoidance of harm in the future. Indeed, any performance enhancement arising from formal reviews may translate to building a safer, more effective healthcare system that minimises the risk of patient harm. ²

An essential first step for health organisations, including those who employ paramedics, is to acknowledge that most errors are due to system breakdowns rather than individual transgressions. ³ There are rare exceptions to this, when individuals wilfully or recklessly act against expected standards of care. Fortunately, these are exceptions, and as described by Watchter & Pronovost (2009), most errors are ‘… committed by competent and committed caregivers [which are] best dealt with by focusing on improving systems rather than people’. ⁴ Thus, a systems approach to error and feedback is crucial for development and implementation of defences, barriers and safeguards, ⁵ as well as avoiding inappropriate apportioning blame. ⁶ A systems approach acknowledges that patient safety errors in healthcare have complex origins and contributors, therefore a balance between system factors, blame and individual accountability is essential. ⁷ While such concepts are not new, and many jurisdictional ambulance services continue to work towards a positive patient safety culture, it is essential to continue efforts to remove barriers to reporting error, advancing professional maturity, and fostering a culture of patient-centred care. ²

Error

Recognition that error will occur is normalised in many industries and professions. For example, in manufacturing, the Six Sigma project management method is centred around an acceptable failure rate of 3.4 defects or failures per million, ⁸ and in forensic science, there is an acknowledged assumption of error, although an acceptable threshold is elusive. ⁹ These examples highlight that errors are common and accepted in many industries, and also raise the question of what is, or should be, the acceptable error rate in healthcare professions such as paramedicine? Further, should an acceptable error rate exist in these contexts at all when the failure may affect the life of one or many?

A ‘towards zero’ approach is seen in the aviation industry, where safety performance goals include ‘no accidents involving commercial air transport that result in serious injuries or fatalities’. ¹⁰ Other high-reliability organisations (HROs) strive for (and consistently achieve) error free operations over extended periods. ¹¹ Such concepts have translated to other areas of healthcare. For example, triggered by the avoidable or potentially avoidable deaths of seven babies in Victoria, Australia, the 2016 ‘Targeting Zero’ report outlines goals analogous to those seen within HROs. ¹² As its title suggests, the goal of the ‘Targeting Zero’ report is to instigate change and eliminate avoidable in-hospital harm. Whilst this target is both ambitious and audacious for any health care system, it is perhaps such goals that are required to drive improvement, quality, and patient safety in healthcare.

Medical error and its impacts on patients, families, and health-care providers have been well-described. The Institute of Medicine's 1999 report found that as many as 98,000 people die in American hospitals every year as a result of preventable medical errors, ² with a major finding that systems and processes regularly fail to prevent error. In Australia this trend is also seen, with adverse event rates in Australian hospitals approaching 7%, with medical error the third-leading cause of death. ¹³ In the out of hospital setting, research into medical error has largely focused on medication safety and clinical error.^14–16 Beyond this, little has been published on error in paramedicine and its links to patient safety and individual and organisational accountability.

Despite an enhanced focus on professionalism in paramedic practice following the registration of Australian paramedics as health professionals, ¹⁷ and with that a mechanism of accountability, a positive patient safety culture may still be lacking in many jurisdictions. ¹⁸ For instance, reporting of errors or near misses may be low due to a perceived lack of psychological safety for the reporters and others involved in the patient safety event. ¹⁵ Formal review of errors in healthcare may also, at times, be considered negative or punitive, ¹⁹ with participants possibly fearing recrimination for their perceived shortcomings. As has been reported in medication safety incidents, this may in turn lead to under-reporting of error and patient safety events, hindering opportunities for improvement. ²⁰ An additional challenge to clinician self-reporting may be the ‘closed’ nature historically associated with jurisdictional ambulance service patient safety event reviews. Whilst aiming to preserve the privacy of the clinicians involved in incidents, lack of transparency in the review process may paradoxically perpetuate misinformation about remediation for the clinician or clinicians. For clinicians, including paramedics, to feel safe to report incidents and to participate in a collaborative and more ‘open’ patient safety review, the organisational quality assurance and improvement strategies should be integrated in the process. ²¹ This facilitates a shift of the focus from individual error and outcomes to a system focus, contributing to a culture of accountability at both individual and organisational levels. ²²

Accountability, ownership and culture

Accountability incorporates the procedures and processes by which one party justifies and takes responsibility for its actions. Associated with the concept of accountability are terms such as liability, ownership, as well as the dysphemism ‘blame’, which have also been defined as a set of expectations for the appropriate response to harmed patients. ²³ Historically, accountability within medicine has focused on the individual, or the lead clinician, in charge of a patient's care. James Reason termed this the ‘person-approach to the human error problem’. ²⁴ Here, the individual is blamed, and unfortunately in some instances shamed, for their contribution to an adverse event. In the hope of preventing future transgressions, the individual may then be penalised or punished. While it may be convenient for healthcare institutions, this individualised approach to human error segregates the unsafe act from the wider system, and in doing may perpetuate a ‘culture of blame’. Such an approach may have contributed to the historical patient safety culture in paramedicine.

There are a range of unintended consequences associated with a blame culture. Nursing studies have found that a blame culture increased staff turnover and negatively impacted staff health and wellbeing, evidenced by psychological stress and trauma. ²⁵ Moreover, within nursing, medicine and other high-risk industries, a blame culture has discouraged reporting of error, adverse events or near-misses due to fear of retribution, impacts to professional reputation or unjustified reprisals. ²⁶ It is apparent that a blame culture not only impacts the foundations of an effective risk management system (i.e. error reporting), but also thwarts individual growth and organisational pursuit of a positive patient safety culture. Although comprehensively studied within the wider healthcare community, research on blame culture within paramedicine specifically is limited to a few studies. One example is a 2013 Australian study investigating the cause of adverse patient events in out-of-hospital care, which reported that in cases with serious patient harm, 33% of respondents had not completed incident reporting due to fear of personal or professional consequences. ²⁷ Similarly, a 2020 United Kingdom study exploring paramedic perceptions of feedback identified that inappropriate blame attribution was a barrier to learning, and that a ‘just culture’ may enable both individual development and progression of the profession. ²⁸

Additionally, titles designated to patient safety events and paramedic vernacular surrounding error, blame and individual accountability may also be a symptom of ‘blame culture’ in paramedicine. Anecdotal reports from paramedics across the international landscape describe titles such as ‘fitness to practice investigation’, ‘clinical variation’ and ‘serious incident’ as well as common language and phrasing around patient safety incidents, such as ‘I’ve received a clinical breach’ or ‘I’m being clinically reviewed’. Notably, these examples focus on individual accountability (or blame), neglect the influence of broader system and make no direct reference to the patient's experience.

A patient-centred focus

Professional evolution in paramedicine is dependent on a positive approach to patient safety that favours a ‘just culture’. Coupled with a person-centred focus, this approach should strive to embrace the individual patient as a person who has unique needs and goals of care. ²⁹ The assumption is that such an evolution will ultimately lead to increased efficacy in health service delivery, and improved patient outcomes and experience. ³⁰ The patient-centred approach can make health care safer and of higher quality, ³¹ as a result of recognising and responding to the perspective of the patient. As paramedicine becomes better integrated into the wider health care system, there is hope for incorporation into systems governance and contemporary quality assurance frameworks. In Australia, these include the Australian Charter of Healthcare Rights, the Australian Safety and Quality Framework for Health Care, the National Safety and Quality Health Service Standards and a range of state-based initiatives. ³² It is this person-centred focus which recognises the importance of partnerships between patients and health care providers and also fosters the promotion of accountability within individual patient care, which are essential for patient safety and patient experience, and an important step for the paramedic profession.

Patients and their support network must be at the centre of their care and, as such, should be involved at a systems and service level in terms of policy and program development, quality improvement, patient safety initiatives and healthcare design. These system attributes are not only demonstrative of professional maturity and ownership, but also exemplify a robust, accountable organisation that can fully involve patients and their families. The implementation of patient centred care within organisations providing out-of-hospital care is vital, as is the presence of organisational systems and processes and a paramedic profession possessing the knowledge and skills to routinely place patients at the centre of their care. The effectiveness of this approach is supported by a wide body of evidence. ³³ Every paramedic is responsible for improving the patient care experience, and enhancing accountability is a core component to improving patient-centred care.

Next steps in the evolution of paramedicine

As jurisdictional ambulance services and the broader paramedic profession work to build an enhanced patient safety culture, we must reflect on the workplace culture within our respective organisations and strive for continuous refinement of both processes and systems. Self-identification and reporting of patient safety incidents is essential in establishing a positive patient safety culture. However, this will continue to stall if clinicians feel unsafe, fear retribution ¹⁶ or lack confidence in the reporting and review processes. Any review of patient safety incidents should be underpinned by key patient safety concepts such as ‘systems thinking’ and an open ‘just’ culture. ¹¹ A mature review process must also be fair, focusing on systems and not individuals, and provide support to both staff and patients involved. Furthermore, the analysis of any event should focus on ‘what happened?’, ‘why did it happen?’ and ‘how could it be prevented from occurring again?’. ³⁴

Efforts to analyse, establish and improve positive patient safety culture in jurisdictional ambulance services must be recognised.^35,36 However, work is needed to reassure clinicians that reporting and sharing their errors will not be detrimental to their employment or status as a paramedic. Central to this work is a patient safety incident management system that is non-punitive and, as such, moves away from a ‘culture of blame’ allowing a culture of self-reporting to thrive. To further foster a positive patient safety culture and encourage adverse or near-miss reporting, the incident management system must also be accessible, user-friendly and transparent from start to finish. ¹¹ Additionally, closure should be afforded to the paramedics to reinforce individual and organisational support, and future incident reporting. Following collation and analysis and consent from those involved, information can then be used to generate patient-centred recommendations for future practice.

Whilst organisations must take responsibility for ensuring the workplace is safe for clinicians to report adverse events without fear of performance management or reprisal, the individual paramedic must also reflect on the changed responsibilities incumbent upon them as professional clinicians. The Paramedicine Board Professional Capabilities for Registered Paramedics Domain 4 outlines the attributes of the Safety and Risk Management Practitioner, which includes a requirement to participate in audit, and to reflect on and review practice and to participate in the teaching, mentoring and development of others. ³⁷

With enhanced transparency of adverse events, mature review processes and acceptance and translation of recommendations, there will come a shift in the culture. From the perspective of registered health professionals, the time has come for both clinicians and organisations to be accountable and accepting of their essential role in review and audit of near misses and adverse events. Paramedicine can hope to see a path forward, where courageous individuals are empowered to identify clinical error and speak up, promoting growth across organisations. Importantly, we must prevent individual paramedics feeling ashamed or in fear of consequences. Only then can we see a true patient-centric safety culture in paramedicine, that concurrently supports clinicians’ growth and development.