2. What is E.V.E.N.T.? System to collect and utilize information from untoward events to help improve consistency and quality of EMS care Anonymous, non-punitive, confidential Help identify needed changes in systems and processes without placing blame on individual providers Modeled after Pennsylvania system

3. Who Developed E.V.E.N.T.? Center for Leadership, Innovation and Research in EMS National Association of Emergency Medical Technicians National EMS Management Assn Emergency Medical Services Chiefs of Canada National Association of State EMS Officials North Central EMS Institute

4. How Does It Work? 1.Provider submits report on event via EVENT website 2.Report reviewed by CLIR staff Ensure report meets criteria Identifying info removed (name, agency, electronic signatures, URL components, etc.)

5. How Does It Work? 3.Report sent to State EMS agency 4.Events posted to Google Group Enroll by emailing clirems@gmail.comclirems@gmail.com Name, EMS agency or affiliation Notification within 48 hours Does NOT include State where incident occurred

6. How Does It Work? Aggregate Reports – Compiled quarterly and annually – Sent to States – Distributed to site partners Encouraged to send electronic copies to their members – Posted on Google Groups – Posted on E.V.E.N.T. website – Email announcement sent to Google Group list

8. Who Can Submit a Report? Any individual who encounters a problem or recognizes a situation in which a safety event occurred – EMS Providers (any level) – Supervisory personnel – Persons involved in care of patient post-EMS

9. What is a Reportable Event? Patient Safety Event Near Miss Event Line of Duty Death

10. Patient Safety Event Event/action leads to worsened patient outcome – System problems – Operations issues – Drug administration errors – Equipment failures or provider errors of omission or misuse – Any clinical aspect of patient care

11. PatientSafetyEvent

12. Patient Safety Event Reports United States, December 2010 – Patient Died, ambulance response delayed United States, January 2011 – Morphine given instead of Diphenhydramine United States, July 2011 – Patient Harmed, Stretcher latch failed, stretcher and patient fell to ground United States, May 2012 – Patient Harmed, Succinylcholine given to pt rather than Cardizem due to expiration date label placed improperly

13. Near Miss An unplanned event that did not result in injury, illness, or damage, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage.

14. NearMissReport

15. Near Miss Reports United States, March 2011 – Near Miss, IO drill bit broke during procedure United States, February 2012 – Near Miss, IV tubing had port factory installed backward, oral version of medication administered instead United States, March 2012 – Near Miss, Large patient rolled on stretcher, tipping stretcher over United States, April 2012 – Near Miss, nurse reported child transported improperly restrained

16. Line of Duty Death Registry Designed by EMS practitioners to share information regarding line of duty deaths State EMS Director and National EMS Memorial Service are notified via email

17. Recalls Ambulance and EMS Equipment recall notices are sent to the State agency and posted on Google Groups and the E.V.E.N.T. website

18. Site Partners Site Partners National ACEP CAAHEP CoAEMSP CECBEMS EMS Chiefs of Canada NAEMD NAEMT NAEMSP NASEMSO NEMSMA NEMS Memorial Service Nat’l Org of State Offices of Rural Health NREMT NVFC

19. Site Partners Site Partners STATE Iowa EMS Assn New York State Vol. Amb. & Rescue Assn North Dakota EMS Association Oregon EMS Association Pennsylvania Emergency Health Svcs. Council South Carolina EMS Association OTHER Humboldt General Hospital EMS Rescue North Central EMS Institute

20. www.emseventreport.com 800/603-4426 For More Information:

21. Thank You!