It is Christmas Eve and you are an engine company commander. The engine responds for a burn injury. A 3-year-old has second degree burns after spilling fondue oil at the Christmas party. The ambulance company that handles 9-1-1 calls for the jurisdiction is usually on the scene within 9 minutes. It has been 20 minutes since the engine arrived and the dispatcher says the ambulance is still “… at least 10 minutes away.” Do you continue to wait for an indefinite time or do you place the child and parent in your rig and transport to the hospital?
I have posed a similar question to hundreds of emergency service providers attending a university course, a fire officer credential program or Just Culture presentation. Very few of them elected to continue to wait for the ambulance. Neither did Major Corey Britt, the Senior Company Officer at Oklahoma City Fire Station 34, when they responded to this Christmas Eve burn incident. (Meyer)
The students are shocked when the correct response from the formal organization’s perspective is to continue to wait for the ambulance. Major Britt was in a disciplinary hearing last Friday for his decision to transport the child and mother to the hospital on fire apparatus. (Yager)
The Just Culture Approach
The “Just Culture” approach can assist high consequence organizations (airlines, healthcare, and 24/7 industries) in holding its system and staff accountable within a supportive environment that provides a non-punitive means of reporting errors, while demonstrating zero tolerance for risky behavior. (Woods and Dekker)
It is a system of justice – using investigatory and disciplinary actions – that reflects what we know of socio-technical system design, human free will, and our inescapable human fallibility. (Nance)
Organizational members have three duties:
- Avoid causing unjustifiable risk or harm
- Follow a procedural rule
- Produce an outcome
After A Bad Outcome Event Occurs
Professor Sidney Dekker, founder of the Safety Science Innovation Lab, describes two approaches to just culture. Retribution imposes a deserved and proportional punishment while Restoration repairs the trust and relationships that were damaged.
The investigation of the bad outcome event looks at:
- What happened?
- What normally happens?
- What does the procedure require?
- Why did it happen?
- How are we managing it?
During this inquiry, we check to see if there is alignment of the department’s mission and value. Is there a clear understanding of the duty, what is defined as a breach of that duty and what are the consequences of breaching that duty.
The inquiry conducts an analysis to identify failed or absent defenses that takes a hazard or risk and makes it a loss, using the human error concepts developed by Professor James Reason.
Designing A Better System
Analysis of earlier bad outcome events result in four areas where we can design a better system. Emergency services have made such changes based on experience.
Controlling Contributing Factors
Changing the pre-cursors to human error at at-risk behavior. Two examples are requiring responders stop at every red light intersection and wear seat belts.
Adding Barriers
Preventing individual errors. Requiring a spotter when backing up vehicles.
Adding Recovery
Catching errors downstream. An example is checking your colleagues personal protective clothing before entering a hazardous environment.
Adding Redundancy
Establishing parallel elements to ensure safe activity. Using more than one method to confirm proper endotracheal intubation.
Just culture is set up to learn from incidents and identify changes in design, procedure and reward systems to promote better behavioral choices.
Understanding Risk
After understanding “what happened?” and comparing it to “What does the procedure require?” we look at the behavorial choice made and the individual’s understanding of the risk involved. Just culture focuses on three behaviors:
- Human Error is an inadvertent action, slip, lapse or mistake.
- At-Risk Behavior is a choice where the individual did not recognize the risk or believed the choice is justified
- Reckless Behavior is a conscious disregard of a substantial and unjustifiable risk
Evaluating the behavior includes the impact of Imposers. Imposers are persons or organizations who set the standards and rules, determines the risk threshold and renders judgement. EMS operations are regulated by a state agency, usually the Health Department. They issue a permit to jurisdictions to provide out-of-hospital care. They issue a license to individual caregivers.
Failure to follow state EMS regulations could endanger the jurisdictional permit to perform out-of-hospital care. In jurisdictions that charge for transport services, losing the jurisdictional permit could result in losing the ability to bill for services. Transporting patients on fire trucks endangers the jurisdictional EMS permit. From the organization’s viewpoint, losing the state EMS permit is a high risk.
Meanwhile, In Oklahoma City
The Emergency Medical Services Authority (EMSA) is struggling with increased call volume, a workforce thinned by the pandemic, long waits to unload patients at the hospital and more time to disinfect ambulances after transport. This results in fewer ambulances on the road and more late arrivals to Priority 1 and 2 calls.
EMSA Chief of Operations John Graham states that with fewer ambulances on the street, more of the responses are coming from the hospitals instead of community posts. This may place the ambulance 15 to 20 miles further away from the incident scene. In December 2020 there were 40 ambulance responses that took longer than one hour for the ambulance to arrive. (Meyer)
An Area With No Pre-planned Guidance
It is not clear if Engine 34 received an accurate estimated time of arrival for the ambulance assigned to the burn incident. (Yager) They had been on the scene for 16 minutes and were told the ambulance was at least 10 minutes away. The Oklahoma City Fire Department regulations may not include guidance on this type of situation.
Dana Libby, a former firefighter/paramedic, police officer and executive with a faith-based international charity organization, observed that the Doctrine of Necessity, along with necessary safeguards, has long been recognized in civil and criminal law. (Christie)
Libby further states:
Every Standard Operating Procedure should start with a statement of policy, principle, or purpose. The enumerated procedures should provide guidance on fulfilling the policy, principle or purpose, under a set of circumstances.
If the circumstances and conditions differ, there is at least guidance concerning what you are supposed to be accomplishing . . . good training, creativity, experience and wisdom will then get you as close as possible to the goal.
Take-Away for All
Many jurisdictions and state medical agencies have made changes in clinical and operational guidelines in response to the COVID-19 pandemic. The transport of critical patients when no ambulance is available is no longer an obscure “what-if” but now a “what-when” scenario. What is a just procedure for the patient, family, emergency responders, and healthcare staff?
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Christie, George C. (1999 March) The Defense of Necessity Considered From The Legal and Moral Points of View. Duke Law Journal 48 (5), Accessed January 25, 2021 https://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1052&context=dlj&fbclid=IwAR10x3HC831W5BqI2pNo1pFzsWz17e48gzjw2qYBBt5uGa2kpKY59mI1Zug
Dekker, Sidney (2017) Just Culture: Restoring Trust and Accountability in Your Organization. 3rd edition. Boca Raton, FL: CRC Press, Taylor & Francis Group. ISBN 978-1-4724-7578-7
Meyer, Ali (2021 Jan 19) EXCLUSIVE: ‘The system failed us’ – Family disappointed in EMSA ambulance delay. Oklahoma News 4. Accessed January 23, 2021 https://kfor.com/news/local/exclusive-the-system-failed-us-family-disappointed-in-emsa-ambulance-delay/
Nance, John J. (2008) Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT: Second River Healthcare, ISBN 978-1-93640-604-3
Reason, James (1990) Human Error. New York: Cambridge University Press. ISBN 978-0-521-31419-0
Woods, David D., et al (2010) Behind Human Error, Second edition. Burlington, VT: Ashgate Publishing Company. ISBN 978-0-7546-7834-2
Yager, Peyton (2021 Jan 22) Oklahoma City Fire Major faces punishment within the department after driving burn patient to the hospital after ambulance delay. Oklahoma News 4. Accessed January 23, 2021 https://kfor.com/news/local/oklahoma-city-fire-major-faces-punishment-within-the-department-after-driving-burn-patient-to-the-hospital-due-to-ambulance-delay/