Document Detail


Communication errors in dispatch of air medical transport.
MedLine Citation:
PMID:  21034233     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Communication errors are a source of preventable medical errors. In high-risk health care settings, identifying the source and addressing root causes can reduce error and improve patient safety. While air medical transport is a high-risk setting, its sources and rates of error have been investigated only within the last several years.
OBJECTIVES: This investigation examined the rate and types of communication errors during call booking of interfacility air medical transports. The primary objective was to determine the incidence and type of errors when the initial requests for transfer took place between the sending facility and transport medicine communication center. The secondary objective was to identify potential underlying causes of these errors.
METHODS: Requests for urgent and emergent interfacility air medical transfers were examined prospectively during a consecutive two-week period. As the first step in call booking, sending facility staff speak directly to communication center staff and are asked for administrative, demographic, and medical details to determine patient acuity and call priority. After this information was captured, investigators contacted the sending facility to verify the information and identify any communication errors. Errors were classified as major (potentially impacting care) or minor (unlikely to impact care) and as errors of omission or commission. Common error types were presented to a management focus group to identify potential contributing causes for these errors.
RESULTS: One hundred twelve calls were randomly selected during the study period, with 98 meeting study criteria. Of those, 41 (42%) calls contained a total of 65 errors. Eleven were classified as major, including five errors of omission and six errors of commission. The most common major errors were recording "no drug allergies" when a drug allergy was present (n = 4), incorrect diagnosis (n = 2), and failure to record that patients were intubated or required mechanical ventilation (n = 2 each). There were 54 minor errors, including 41 omission errors and 13 commission errors. Nearly half the errors were attributed to procedures and software. No identified error resulted in patient harm or an adverse outcome.
CONCLUSIONS: Communication-based errors are common in the initial phases of call booking in air medical transport. Human and process-driven errors contribute equally to these errors.
Authors:
Daniel Vilensky; Russell D MacDonald
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Publication Detail:
Type:  Journal Article     Date:  2010-10-29
Journal Detail:
Title:  Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors     Volume:  15     ISSN:  1545-0066     ISO Abbreviation:  Prehosp Emerg Care     Publication Date:    2011 Jan-Mar
Date Detail:
Created Date:  2010-11-24     Completed Date:  2011-06-02     Revised Date:  2012-04-04    
Medline Journal Info:
Nlm Unique ID:  9703530     Medline TA:  Prehosp Emerg Care     Country:  England    
Other Details:
Languages:  eng     Pagination:  39-43     Citation Subset:  IM    
Affiliation:
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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MeSH Terms
Descriptor/Qualifier:
Air Ambulances / organization & administration,  statistics & numerical data*
Communication*
Emergency Medical Service Communication Systems*
Emergency Medical Services / organization & administration,  statistics & numerical data*
Focus Groups
Humans
Incidence
Medical Errors / prevention & control,  statistics & numerical data*
Ontario
Patient Transfer / organization & administration,  statistics & numerical data*
Prospective Studies
Risk Assessment

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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