Page 17 - PFFW December 2018
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 Classification and Taxonomy
   Patient Safety Event Classification & Adverse Event Reporting Policy of EMS Agency
 Sentinel, Serious, Safety, Precursor, Serious Circumstances
   Safety Event Taxonomy
  Procedural, Environmental, Patient Protection, Care Management, Device, Criminal
   Individual Error Taxonomy
 Competency, Consciousness, Communication, Critical Thinking, Compliance
   System Error Taxonomy
   Structure, Culture, Process, Policy or Protocol, Technology, or Environment
  Source: Milwaukee County EMS, OEM-EMS CQIP Revised 5-9-2018
support and coach EMS providers in making safe choices, understand at-risk behavior and reduce the rate of human error to make EMS care as safe as possible. The Just CultureTM algorithm also ensures a consistent process that providers can understand, feel is just and have confidence in the process.
Just CultureTM identifies three duties of EMS providers:
1. Duty to Avoid Causing Unjustifiable Risk or Harm 2. Duty to Follow a Procedural Rule
3. Duty to Produce an Outcome
The product of the Just CultureTM algorithm produces four outcomes:
1. Support the Provider
(ensure compassion and empathy)
2. Coach the Provider
(values-supportive discussion on the need to engage in better choices; targeted educational remediation likely)
3. Counsel the Provider
(notice that performance is unacceptable; action plan for improvement)
4. Discipline the Provider
(punitive such as clinical privilege suspension or revocation)
The overwhelming outcome of this Just CultureTM algorithm focuses on the support and coaching of the provider, improving the tools providers need to perform their jobs, minimizing “second victim” phenomena when a patient
safety event occurs and justly balancing the mission to deliver excellent care. Whenever a patient safety event occurs, any Just CultureTM outcome (support, coaching, counseling, or discipline) would be delivered in collaboration between the EMS provider, medical director, employer and other key Continuous Quality Improvement Program (CQIP) members.
Targeted education remediation should be developed and overseen by the organization’s EMS Education Manager in cooperation with the medical director and provider employer; counseling, development of a corrective action plan, or punitive actions should be developed by the medical director in cooperation with the provider’s employer, including labor representation, if applicable.
Formal discipline should be extremely rare and be reserved for outcomes that show willful reckless preventable action. When that occurs, the discipline should be measured,
We must have a consistent, practical, and fair way to safeguard the mission to be the best EMS providers possible. We must also recognize that human error can occur.
progressive, proportional and fair. We are trying to correct behavior, and the discipline necessary to achieve that result should be the focus. After the event, the provider still must make critical decisions during high-acuity events, and they cannot spend that event second guessing themselves out of the fear of significant discipline if they screw-up. It is important
to understand that the severity of the adverse event is not proportional to the severity of outcome; they are independent. Discipline is only used for choices or behaviors that knowingly cause harm; the algorithm focuses more on decisions or choices than on outcome.
It’s mission critical that we have a Labor-Management Initiative the produces a top-notch CQI program, and that all members of the organization fully embrace it. If it’s done correctly, everyone wins. If we can embrace these concepts when fires don’t go as planned, we can do it for EMS events that don’t go as planned. A “near-miss is a near-miss” regardless if it’s on fire or in respiratory distress. For those that attended WALTS, you heard from Dr. Ricardo Colella, MCEMS Medical Director on this topic. The MCEMS CQI documents are posted on the PFFW WALTS website for your review. f
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