016 Occurrence reporting and significant events during aeromedical transportation: a review of 18 months of retrievals by the Scottish Emergency Medical Retrieval Service (EMRS)
Authors: Moultrie C E , Corfield A R , Hepburn S 
Published: September 2011

Objectives and Backgrounds

Human factors represent a substantial contribution to significant events in high-risk professions, including medicine and aviation. Aviation has acknowledged this and introduced confidential reporting systems to include human factors, significant events and mandatory occurrence reporting, even if no harm occurs, so that patterns which contribute to significant events or outcomes can be identified. Such systems are being accepted within Emergency Medicine, but without universal implementation. We aimed to investigate current EMRS practice to determine the occurrences which affect an aeromedical retrieval service with an established, integral event reporting system.

Methods

Over an 18-month period we looked at 323 aeromedical retrievals undertaken by the physician led team. Data from each mission was reviewed by a blinded third party to look for evidence of non-normal occurrences. This was compared against the formal significant event reports filed.

Results

The data are summarised below, categorised similarly to that published by other services (table 1) and alongside a breakdown of occurrences (table 2).

Abstract 016 Table 1Event typeSub-type and number of events (percentage of missions affected)Number of events (percentage of missions affected)Critical events1 (0.3)Significant eventsSystem-based42 (13.0)Equipment14 (4.3)Other28 (8.7)Patient-based93 (28.8)Physiological48 (14.8)Other45 (13.9)OccurrencesSee Abstract 016 table 2.257 (67.2)Abstract 016 Table 2Occurrence reported (category)Instances of occurrence (percentage of missions affected)Total no. occurrences reported257Total no. missions with occurrences reported213 (67.2)Simultaneous retrieval72 (22.3)Helicopter availability45 (13.9)Clinical event35 (10.8)Adverse weather32 (9.9)Equipment problem24 (7.4)Aircraft technical14 (4.3)Fixed-wing availability12 (3.7)Road T/F delays9 (2.8)No air asset available7 (2.2)Airport/ATC problems5 (1.5)Bed/hospital availability2 (0.6)

The data in Abstract 016 table 2 are based on n=317 missions which were suitable for occurrence analysis.

Conclusions

Our aeromedical service has adopted an open reporting culture and staff are encouraged to record near misses, positive learning experiences and actual significant events. All significant events are investigated and reported in a no-blame fashion as part of clinical governance meetings. Our data shows that significant event reporting does not include a large number of non-normal occurrences. Although most of these occurrences are low impact, and indeed are often accepted as part of normal practice, evidence from aviation has shown that recording of these can allow early identification of potential hazards before harm occurs. Therefore, we have introduced a prospective event review system which more closely resembles that used in aviation. We are currently collecting prospective occurrence data from our aeromedical system in this format to present alongside the above data at CEM Scientific Conference 2011.