Do Paramedics Make Mistakes?

A newspaper article recently caught my eye. It was headlined, "Medical Study Shows Epidemic of Errors." According to the article, by some estimates, more people die each year from hospital medical errors than from car accidents. So many people are injured by medical mistakes that the Institute of Medicine has declared an epidemic of errors.

The published report indicated as many as one million patients each year are harmed by medical mistakes and 120,000 die from them. Hence, medical mistakes cause three times more deaths than car accidents each year. Some of the mistakes range from slight overdoses that cause mild side effects to misdiagnoses and even amputations performed on the wrong limb. If these mistakes are made in a controlled hospital environment, how many mistakes do you think are made in the field by paramedics?

Providing EMS can be a high-speed, demanding and adrenaline rush on the cutting edge. The job demands that no mistakes be made when lives are at stake, and many times there are no second chances. Working in the field is not the same as working in a well-lit emergency trauma room where scores of medical professionals, diagnostic tools and other resources are available. In the field, it is usually you and your partner, and if you are lucky, an engine company, and you are working many times in cramped, dark and confined spaces. (Is it just me or does it seem like every person who suffers a cardiac arrest does it in a cramped second-floor bathroom?)

With all these thoughts in mind, during a recent visit to a firehouse for an invited lunch, I posed this question to the paramedics: Have you as a paramedic ever made a mistake? To the firefighters in the room, I asked this question: Have you ever seen a paramedic make a mistake? Not surprisingly, none of the paramedics present admitted to making a mistake during patient care, even after some good-natured ribbing and pressure from the non-paramedics in the room.

But then the talk turned serious. Many of the firefighters said they have seen some terrible paramedics in the past, some who had no business even doing patient care, leading them to wonder how they made it through paramedic school.

One person said he would never forget one incident: as a member of an engine company he pulled up to a scene where a person had been struck by a car and an ambulance was already on the scene. He saw the patient lying in the middle of the street, completely cyanotic and not breathing, while the two paramedics were standing near the ambulance, talking to a police officer. A member of his engine company did a quick assessment and found the patient had a pulse, but was not breathing. He merely opened the airway and began bagging the patient. Within seconds, the patient "pinked" right up. Apparently, the two paramedics had done a poor assessment and pronounced the patient dead.

One paramedic finally admitted that they have done countless life-vs.-death procedures, such as intubation and thoracic decompression, but never recalled worrying much about killing someone by mistake. He further explained that the training, culture and protocols were designed to make at least the most avoidable kinds of deadly errors reasonably unlikely. But he admitted that what really scared him was screwing up some non-life-threatening procedure with grave consequences. The examples he cited included paralyzing an accident victim by rough handling and failing to notice secondary injuries during an examination.

The reality is that paramedics are human and can make mistakes. But several questions need to be answered when the mistakes are made. First, were the actions negligent or grossly negligent? When a paramedic is grossly negligent, the actions are willful and wanton. Essentially, there is intent to harm or the paramedic was conscious of the potential repercussions of his or her actions.

Some would argue that two paramedics need to be on every call in order to have a "check and balance" system in place to prevent mistakes. Those against a two-paramedic response point to countless studies showing no significant difference in clinical outcomes of patients in a two-paramedic response vs. a one-paramedic/one-EMT response.

The Institute of Medicine report said health care is a decade or more behind the aviation industry in responding with systems that forgo finger-pointing and build in multiple backups. Air travel is safe because it is not about pilots performing perfectly - it is about systems supporting reliable performance.

Many argue that paramedics making mistakes is a system problem. Instead of encouraging paramedics to report errors to determine what went wrong and why, many systems discipline them. The question we need to ask is not who made the mistake, but why the mistake was made. Only after it is determined how the mistake was made can the system be fixed.

If this conversion within EMS to a non-punitive, "let's find out why things are going wrong" approach is to be successful, then each fire department will need to create a reporting system that is exempt from public-disclosure laws. It would be unrealistic to believe that paramedics can report their errors freely in some form of a patient-safety reporting system and then have it used against them in a court of law. Additionally, fire departments must analyze errors to determine how future mistakes can be prevented.

So, do paramedics make mistakes? Every day! Some are small and some are enormous. Do most paramedics make mistakes intentionally? No. The key to improving EMS care in the field is realizing our blunders and making sure they do not occur again.