Caring for our Caregivers

There is growing and significant interest in EMS provider mental health.  This has been attributed to the increasing number of stories about provider mental health issues.  EMS leaders from around the country are taking notice and looking for ways to improve as well as implement the best support for our men and women on the frontlines of healthcare.  The Center for Patient Safety has likewise been concerned about this distressing and often not discussed topic.  There are likely many causal factors for these cases, regardless; each one is tragic as many providers have no place to turn.

Being a provider can bring unique challenges that are often only understood by another provider.  One unique program that is available is the Second Victim Program.  This program has been developed by health care professionals that understand those unique challenges.  Please join the Center for Patient Safety on September 3rd for a free webinar to learn more about the Second Victim Phenomenon and how this program might help make a difference. To register or read more.

Second Victims in EMS

Being an EMS health professional often requires putting emotions aside for the sake of patients. But despite the emotional resilience that allows EMS healthcare providers to care for patients under stressful, high-stakes circumstances, sometimes an unexpected clinical event or outcome can have a heavy emotional impact.

Earlier this year, a paramedic took her life following a 25 year career in EMS:

“Really, EMS sees it all. It’s the accumulation of that exposure to trauma that gets really wearing,” Kim Gorgens said, a former paramedic and now clinical associate professor at Denver University. Gorgens said the industry must do better to recognize, and treat those who are suffering.  Read the full article.

Second victims are “Healthcare team members involved in an unanticipated patient event, a medical error and/or a patient related injury and become victimized in the sense that they are traumatized by the event.  Frequently, these individuals feel personally responsible for the patient outcome.  Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.”

Second victims may exhibit a wide variety of physical and psychosocial symptoms. Signs and symptoms of this emotional aftershock may last days, a few weeks, a few months or even longer. Many second victims feel quite vulnerable by the wide ranging symptoms and frequently express that they have never experienced such an intense emotional response in their lives.

Despite the increased understanding of the second victim phenomenon, many of today’s EMS organizations are unaware of how to act on that knowledge to support their health professionals. Therefore, many healthcare providers still suffer alone after an unanticipated clinical event. Through proper social support and guidance, EMS organizations can prevent excellent healthcare providers from experiencing long-term consequences such as prematurely leaving their chosen profession or experience prolonged professional and personal suffering.

If you are interested in learning more about implementing a second victim support framework within your health care setting, there are several resources available.

In collaboration with the University of Missouri Health System Second Victim Program, the Center for Patient Safety is pleased to host the following workshops:

September 24, 2015 from 7:30-3pm

September 3, 2015 12:00-1:00

CPS is pleased to speak on upcoming First Watch webinar!

First Watch Header

Wednesday, July 22nd at 10 am PT/12 pm CST  Register Now for this Webinar

Patient Safety Organizations are becoming an integral part of the safety of our our patients and caregivers. For the benefit of your agency and it’s people, we highly recommend you learn more about the benefits of joining a Patient Safety Organization (PSO). Being part of a PSO can reduce legal exposure to issues found during your QI process and lead to better, safer, patient care.

We recognize that every agency operates differently and has different needs, and would like to provide you with two different webinar opportunities to learn more about what one or both of these PSO organizations have to offer.

In this webinar you will learn how participating with a Patient Safety Organization (PSO) can protect the quality and safety work in EMS, as well as support your EMS staff.  Participating in a PSO can provide a number of benefits like improved patient safety and quality improvement, or becoming proactive in preventing adverse events and unsafe conditions instead of just being reactive.

We think this is very important, and we highly encourage you to attend this webinar to learn more about becoming a member of a PSO, and the benefits each offer their members.

Wednesday, July 22nd at 10 am PT/12 pm CST

As a federally listed Patient Safety Organization (PSO), CPS is a private not for profit organization that works with EMS. There are many benefits to participating with a PSO, including federal protection and confidentiality privileges as well as shared learning about adverse events, near misses and unsafe conditions. The Center provides PSO Alerts and Safety Watches as well as offers best practices on up-to-date lessons learned in healthcare. In addition, it supports the creation and maintenance of a safety culture and offers services to measure and improve healthcare culture, such as a safety culture survey, Just Culture training, CUSP eduction, and more.

In this webinar you will hear from CPS members John Russell, MD, President of Cape County, MO, Jay Reich, MD of Kansas City, MO and Leo Hsu, MD and John Romeo of St. Charles County, MO, as well as CPS EMS Project Manager Lee Varner.

Register Now for this Webinar

Pilot program launched for EMS behavior health data

The Center for Patient Safety works closely with many EMS services around the United States to improve patient safety and reduce preventable harm. Over the past year EMS leaders have expressed interest to better serve the needs of the mental health population. In the process many of these leaders have discovered there is little data around these encounters and transports. This includes emergency calls or scene encounters as well as inter facility transfers between hospitals.

Therefore, approximately six months ago the Center’s EMS data committee started to explore the opportunity to collect data around these patient encounters. This includes understanding what happens on an emergency scene but also during an inter facility transfer. Recently the committee finalized the data collection formats for this project. Starting this month a pilot program was initiated to collect data and so far participation has been strong.

Why a PSO? Participating with a federally listed PSO (Patient Safety Organization) that works with EMS offers many important benefits. PSO’s were created to support shared learning under the Patient Safety Quality Improvement Act of 2005. A PSO does this with federal safeguards to protect discoverability of event analysis and deliberations. Event information is aggregated and de- identified then shared with participants in various learning opportunities. Many EMS services are hesitant to share data out of the fear of litigation and concern about their public image

The behavior health pilot will collect data around several key areas including provider and patient safety as well as resource utilization. In addition, many leaders would like to understand the frequency and dynamics of specific high risk events such as patient elopement from an ambulance.  Data will also support understanding community’s mental health resources as this often determines the destination for this patient population.

EMS leaders are hopeful that this new area of data collection will help everyone understand the current state more clearly. The Center and its many PSO participants are excited to be involved with this project. Ultimately we hope it drives greater patient and provider safety while we also learn how to save healthcare dollars.

Center for Patient Safety releases Summer PSO Newsletters

The Center for Patient Safety has released the Summer PSO Newsletters.  We’re certain you’ll find something of interest related to patient safety at your organization!  Download the full newsletter to read more on the PSO legal environment, upcoming events, best practices from Hannibal Regional Hospital and Mercy Hospital, St. Louis, and much more!

  • PSO News – a publication for Hospitals and ASCs – Download or View on Issuu
  • EMS PSO News – a publication for EMS – Download or View on Issuu

EMS Insider Article

Allison J Bloom, Esq., and Lee Varner, BS EMS, EMT-P, Center for Patient Safety EMS Project Manager, recently joined up to write an article for EMS Insider.  Read full article in May 2015 EMS Insider Newsletter.

Using Advanced Technology to Pursue Quality & Best Practices
By Allison J. Bloom, Esq. & Lee Varner, BS EMS, EMT-P

Let’s say you have recently returned from a conference or trade show, where you found a great new piece of technology that you want to implement in your agency. Or, maybe you have been tasked with sourcing a new piece of software or technology to enhance the care and services your agency provides in your community. Before you go jumping off the proverbial bridge into the new technology lake, you owe it to yourself and your agency to ask two very important and fundamental questions: 1) what do I need to do to protect and implement the technology on a local level from a best practice standpoint? And, 2) how can I protect the data coming through that piece of technology from being used by attorneys to find fault regarding our quality efforts?

It is no secret that EMS providers are fond of “bright, shiny, new objects.” If it’s cool and it’s new and it will make our jobs easier, we want it! However, recent articles and   commentary by leading scientists and experts are sounding the alarm about artificial intelligence (AI) and its impact on our society. Elon Musk and Stephen Hawking have both indicated that we have a window of   opportunity to understand, as well place controls around, new technologies, because the consequences of AI are far reaching and could impact our future far beyond our current understanding.

Download PDF of article here.

Reduce Medication Errors in EMS

Nobody wants a medication error but often we don’t have a new strategy or method for prevention. Experts suggest that most errors are linked to a flaw in a system design or an unfortunate behavioral choice.  Regardless, working towards prevention requires better processes as well as improving our safety behaviors. To learn more, check out this article by Kim D. McKenna MEd, RN, EMT-P, recently posted at

PSO’s as Standard Operating Procedures

Dr. Jay Reich, EMS Medical Director for the Kansas City Fire Department, presented last week at the EMS State of the Sciences Conference, also known as “The Gathering of Eagles”.   The conference is a unique, and highly respected, conference in EMS.   Each year, the conference offers opportunities to learn about the latest science and advances in EMS, including current research, data and industry innovations.   Those selected to present at the conference are EMS medical directors from the largest EMS systems in the United States.   In addition, other leading experts from around the world present relative information to advance the practice of EMS.

Dr. Reich’s presentation titled “PSOs as SOPs! Getting Patient Safety Organization Buy-In for EMS CQI” shared how participating with a PSO can protect the quality and safety work in EMS, as well as support the EMS medical director.   Since Patient Safety Organizations (PSOs) are fairly new to EMS, Reich outlined some of the benefits of PSO participation, such as, information and key examples of how Kansas City Fire Department is implementing efforts towards greater patient safety and quality improvement. His presentation focused on the ways a PSO supports the EMS shift to proactive efforts to prevent adverse events and unsafe conditions instead of reactive.

Dr. Reich’s full presentation can be found at the Gathering of Eagles website under 2015 presentations.

PSOs as a Risk Management and Compliance Tool

Allison Bloom recently wrote an important article about Mobile Integrated Healthcare (MIH) that was featured in EMS Insider.   If you are providing this care or exploring MIH then you should read Allison’s article and learn more about how participating with a Patient Safety Organization (PSO) can help you.

EMS Services Participating with a PSO can improve quality, safety, & financial performance

Written by Lee Varner, BS EMS, EMT-P
Mike Wallace,
EMS Captain, Central Jackson County Fire Protection District

Does this sound like your EMS service….

Your typical runs include calls for chest pain, shortness of breath, seizures, and even cardiac arrest.  You run these calls day in and day out.  You drop patients off at the hospital just in time to clear for another call.

At the end of the day, ask yourself these simple questions:

  • Do you look back at the calls to determine how well your providers performed from the perspective of protocol compliance or customer service?
  • Do you have performance benchmarks  established, for example time to 12 lead or aspirin administration on chest pain patients?
  • Do you know the percentage of survival for cardiac arrest patients in your community?
  • Do you have a mechanism in place that allows for the self-reporting of events as they relate to medication errors, equipment malfunctions, or near misses?

If you answered yes to all of these questions, great job!   However, some of you probably said no to most.



PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.