Comparison Overview of Prehospital Errors Involving ... - CiteSeerX

1 downloads 0 Views 494KB Size Report
Aug 5, 2008 - Keywords: ambulances; emergency medical service; emergency medical technician; errors; preventable death studies; prehospital; road.

ORIGINAL RESEARCH

Comparison Overview of Prehospital Errors Involving Road Traffic Fatalities in Victoria, Australia Malcolm J. Boyle, M ClinEpi

Monash University, Victoria, Australia Correspondence: Mr. Malcolm Boyle Monash University Department of Community Emergency Health and Paramedic Practice PO Box 527 Frankston 3199 Victoria, Australia E-mail: [email protected] Keywords: ambulances; emergency medical service; emergency medical technician; errors; preventable death studies; prehospital; road traffic fatalities Abbreviations: ALS = advanced life support CCRTF = Consultative Committee on Road Traffic fatalities EMS = emergency medical services EMST = early management of severe trauma ISS = Injury Severity Score IV = intravenous MICA = mobile intensive care unit TRISS = Trauma Score-Injury Severity Score Received: 08 May 2008 Accepted: 03 July 2008 Revised: 05 August 2008 Web publication: 22 June 2009

Prehospital and Disaster Medicine

Abstract Introduction: Until early 2003, the Consultative Committee on Road Traffic Fatalities (CCRTF) in Victoria, Australia was the main body investigating and publishing data about prehospital errors resulting from road traffic fatalities. The objective of this study was to identify and interpret prehospital error rate trends associated with road traffic fatalities during a 10-year period of the CCRTF reports. Methods: This study is a review of the prehospital errors defined in Victorian CCRTF reports of preventable deaths of road traffic fatalities over a 10-year period. Results: Six CCRTF reports contained prehospital data for errors associated with road traffic fatalities. From 1992 to 1998, system errors decreased. However, over the same timeframe, management, technical, and diagnostic errors increased. There was a marked jump in system, technique, and diagnosis errors from 1998 to 2001–2003. However, management errors declined over the same timeframe. The jump in errors in the 1998 to 2001–2003 timeframe coincided with the introduction of advanced life support (ALS) for Victorian paramedics in 2000.The number of preventable deaths decreased from 1992 to 1998, however, there was an increase from 1999 onwards, coinciding with the introduction of the state trauma system and ALS for paramedics. Conclusions: This study demonstrates that there has been an increase in prehospital error rates, especially from 2000, which coincided with the introduction of ALS for paramedics and the state trauma system in Victoria, even though the state trauma system had an overall decrease in error rates. Boyle MJ: Comparison overview of prehospital errors involving road traffic fatalities in Victoria, Australia. Prehospital Disast Med 2009;24(3):254–261. Introduction Until recently, the review of error rates within the prehospital setting in Victoria, Australia had been undertaken by the Consultative Committee on Road Traffic Fatalities (CCRTF). In the Victorian prehospital environment, the CCRTF used a retrospective analysis of ambulance and hospital data to determine if a death following a road accident potentially was preventable.1–7 The CCRTF was set up in 1992 with support from the Victorian Road Trauma Committee, a committee of the Royal Australasian College of Surgeons, and the Victorian Institute of Forensic Medicine, due to increasing international awareness that there were preventable deaths following severe road trauma. At this time, there was a lack of quality information regarding preventable deaths and trauma care associated with road traffic fatalities in Australia. The resulting reports from 1994 to 2003 identified errors or problems categorized by system, management, diagnostic, and treatment errors that were believed to be associated with the patient’s death. Each category is defined in Table 1. This analysis of road traffic fatalities focused on the documentation of the management of the patients and potentially missed errors that were not documented, or that occurred while the patient was in the care of the ambulance crew and hospital staff. The review process examined road trauma vichttp://pdm.medicine.wisc.edu

Vol. 24, No. 3

Boyle

255 Error Category

Criteria

Failure or insufficiency of the trauma system to deliver care appropriately and timely as a result of inadequate facilities or personnel

System inadequacy

A therapeutic or diagnostic decision made contrary to an available data/management plan for the patient and not in accordance with recommended optimal standards of practice (e.g., early management of severe trauma (EMST) guidelines)

Error in treatment/management strategy

Technical error occurring during the performance of a diagnostic or therapeutic procedure

Error in technique

Injury missed because of misinterpretation, inadequacy or lack of clinical examination or diagnostic procedure(s)

Error in diagnosis

Diagnosis not made in a timely fashion when considered in the context of the patient’s overall condition

Delay in diagnosis

Boyle © 2009 Prehospital and Disaster Medicine

Table 1—Error categories and criteria20 tims who died after an ambulance arrived. A previous study by McDermott et al specifically defined prehospital errors for 1997 and 1998.8 The objective of this study was to identify, and when possible, interpret prehospital error rate trends associated with road traffic fatalities over a 10-year period of the CCRTF reports. Methods This study was a retrospective review of reported prehospital errors in six preventable death study reports published by the CCRTF in Victoria, Australia. The CCRTF studies were conducted in Victoria, a southern state of Australia. Victoria covers approximately 227,590 km2. Melbourne is Victoria’s capital and largest city. The Metropolitan Ambulance Service (MAS) provides the emergency medical services (EMS) for the greater Melbourne metropolitan area, which covers approximately 7,694 km2. Rural Ambulance Victoria (RAV) services the remaining 219,896 km2 of Victoria. The state of Victoria has both a single and dual response EMS dispatch system. A basic EMS crew provides the first level of EMS response. Beginning in 2000, advanced life support (ALS) skills (including intravenous (IV) cannulation, laryngeal mask airway (LMA), and selected drugs such as morphine sulphate, metoclopramide, dextrose 50%, glucagon, adrenaline tartrate, ceftriaxone, naloxone hydrochloride, and midazolam) were introduced for basic EMS crews. The second level of EMS response is provided by the mobile intensive care ambulance (MICA) staffed by paramedics who have a broader range of ALS skills, including endotracheal intubation and a greater range of drugs. The state trauma system also began in 2000 and became fully operational in 2002. There were six CCRTF reports reviewed the: (1) 1994 report (01 July 1992–30 June 1993); (2) 1995 report (01 July 1993–30 June 1994); (3) 1996 report (01 January 1996–31 March 1997); (4) 1998 report (01 January 1997–31 December

May – June 2009

1997); (5) 1999 report (01 January 1998–31 December 1998); and (6) 2003 report (Part A, 01 July 2001–30 June 2002; and Part B, 01 July 2002–30 June 2003). Mean errors were not defined in any of the CCRTF reports. Likewise, it is unknown how these mean error rates were calculated. All data pertaining to prehospital errors associated with the management of road trauma victims who died after an ambulance arrived were included. Data for the emergency department, operating theatre, intensive care unit, high dependency unit/surgical ward, and inter-hospital transfer were excluded.The CCRTF had two multidisciplinary medical groups that reviewed a range of medical documents (prehospital through to autopsy reports) to assist them in determining the errors, including those contributing to death. Descriptive statistics, including mean values and standard deviations (SD) were abstracted from the reports. Additional statistical processing was used to summarize and compare the data. Values (e.g., SD) not presented in the relevant report are missing from the tables. Additional statistics, comparisons of means, and proportions, were calculated using EpiCalc 2000 (Version 1.02, Brixton Books, 1998). The results were considered statistically significant if p 20 minutes increased significantly from 10.2% in the 1994 report to 35.6% in Part B of the 2003 report (p

Suggest Documents