Participant Demographics
Out of 2,000 questionnaires distributed, 1 510 were returned, giving a response rate of 76%. Of the participants, 62.6% (n = 909) were men and 37.4% (n = 542) were women (ratio 2:1). The median age was 37.4 years (± SD = 1.14 years), with the majority (40.3%; n = 592) within the age bracket 25–34 years and having worked for an average of 11.2 years (± SD = 8.4). Participants registration cadres are as follows: Basic Ambulance Assistant (BAA) (38.6%; n = 566); Ambulance Emergency Assistant (AEA) (29.4%; n = 432); Emergency Care Practitioner (ECP) (9.4%; n = 138); Emergency Care Technician (ECT) (9.1%; n = 134); Critical Care Assistant (CCA) (8.4%; n = 124); Emergency Care Assistant (ECA) (0.2%; n = 3); and Other (4.8%; n = 71).
Regarding the nature of their employment, the majority (83.4%; n = 1,186) of the participants reported that they worked as operational emergency care practitioners, 11.3% (n = 160) worked as emergency care support staff, and only 5.3% (n = 5) worked in EMS communications. The majority (53.1%; n = 736) of the participants were employed in the private sector, while 46.9% (n = 649) worked in the public sector. Eight-hundred-and-ninety-six (62.9%) participants indicated that their EMS base is located in an urban area, 20.1% (n = 286) indicated that they work in rural areas, and 17.1% (n = 243) worked in semi-rural areas.
Participants' perspectives on types of human error in the pre-hospital emergency care setting
Analysis of the participants’ responses to the types of human error that occur in the pre-hospital environment yielded five dominant themes, namely poor judgement error, poor skill/knowledge-based error, fatigue-related error, human error, and communication error.
Poor judgement error. The majority of the participants reported that poor judgement errors often occur as misdiagnoses, and incorrect medication or dosages, as reported by quotes #1–#8.
#1 “Missed diagnosis”
#2 “Incorrect interpretation of diagnosis”
#3 “Wrong drug dosages”
#4 “Misdiagnosis – mistreatment”
#5 “Miscalculated dosages”
#6 “Misdiagnosis, wrong dose/drug”
#7 “Wrong drug calculations”
#8 “Misjudgement of symptoms”
Poor skill/knowledge-based error. According to the participants, poor skill/knowledge-based error in the pre-hospital care setting can represent as poor clinical reasoning and poor patient management (cf. quotes #9–#11).
#9 “Lack in clinical reasoning leading to wasted time on scene”
#10 “Management related errors”
#11 “incorrectly managing a patient due to lack of knowledge”
In addition, participants listed lack of proper training and failure to attend continuous professional development programmes as among the factors that can precipitate poor skill-based errors (cf. quotes #12–#15)
#12 “Not doing refresher courses”
#13 “Lack of proper training”
#14 “lack of adequate training”
#15 “Not doing clinical updates”
Fatigue-related error. Participants reported that fatigue-related errors often present as lapses in concentration, leading to mistakes when attending to patients (cf. Quotes #15–#17); fatigue is attributed to work overload, lack of rest, stress and burnout, as reported by quotes #16–#23.
#16 “lapse in concentration i.e. mistakes”
#17 “Loss of concentration”
#18 “Poor concentration”
#19 “overloading of work”
#20 “overwork/tired”
#21 “No resting enough before shift”
#22 “stress when dealing with difficult situations, panic”
#23 “Burnout”
Human error. Participants indicated that bad attitudes and behaviours, lack of confidence, and fear leading to negligence in practice constitute some of the human errors occurring in the pre-hospital emergency care setting (cf. Quotes #24–#29).
#24 “Lack of confidence”
#25 “Fear”
#26 “Bad attitudes”
#27 “poor practitioner attitude”
#28 “Negligence”
#29 “Carelessness, Attitude”
Communication error. As described by the participants, communication errors in the pre-hospital emergency care setting could occur because of poor or miscommunication between ECPs, language barriers between the practitioners and patients, and failure to communicate with patients (cf. Quotes #30–#33)
#30 “Lack of effective communication”
#31 “Miscommunication”
#32 “Communication barriers”
#33 “not communicating with the patient”
Factors participants perceive as contributing to human error in the pre-hospital emergency care setting
Analysis of participants’ responses regarding factors that are perceived to contribute to human error in the pre-hospital emergency care setting generated eight emerging themes, namely work related fatigue/stress, insufficient education and training, insufficient clinical knowledge and experience, unsafe work environment, poor communication skills, being overconfident, poor leadership and management practices, and intimidation by and pressure from senior colleagues.
Work related fatigue/stress. The majority of the participants reported that work-related fatigue and/or stress represent a major contributing factor to human error in the pre-hospital emergency care environment (cf. Quotes #34–#39). In addition, work related fatigue/stress was found to correlate with positively fatigue-related error (r = 0.24; p ≤ 0.01).
#35 “Fatigue”
#36 “Stress at work”
#37 “Exhausted/burnt out personnel”
#38 “Stress induced freezing”
#39 “Fatigue and practitioner burnout”
Insufficient education and training. Participants also indicated that insufficient training as well as not attending continuous development programmes could contribute to human error in the pre-hospital emergency care setting as shown in quotes #40–#44. A high positive correlation was found between insufficient education and training and poor skill/knowledge-based error (r = 0.92; p ≤ 0.01).
#40 “Poor training”
#41 “Lack of knowledge and training”
#42 “Lack of education/training/revision”
#43 “Not enough training”
#44 “Lack of continuous development”
Insufficient clinical knowledge and experience. Limited clinical knowledge, as well as lack of experience in pre-hospital emergency care, were also suggested by the participants as factors that may lead to human error when attending to patients in the pre-hospital setting (cf. Quotes #45–#51). This factor was found to correlate positively and significantly with poor skill/knowledge-based error (r = 0.83; p ≤ 0.01).
#45 “Lack of exposure or lack of experience”
#46 “Not knowing the work”
#47 “Lack of knowledge”
#48 “Lack of clinical knowledge”
#49 “Insufficient skills set or knowledge”
#50 “Lack of adequate experience”
#51 “No knowledge”
Unsafe work environment. Participants of this study, furthermore, indicated that fear for personal safety and stress associated with working in an unsafe environment contribute to human error in the pre-hospital setting, as exemplified by quotes #51–#57.
#51 “Unsafe environment”
#52 “Danger... crime.. .gangs... rioting”
#53 “Extreme stress due to threat to your life”
#54 “Fear of being mugged end up doing mistakes if working in the red zone”
#55 “Red zones. Safety”
#56 “Environmental danger”
#57 “Fear of personal safety”
Poor communication skills. Miscommunication, inability to communicate effectively, and lack of communication was cited by the participants as factors that can contribute to human error in the pre-hospital emergency care setting (cf. Quotes #57–#61). Similarly, the factor, poor communication skills correlates positively with communication error (r = 0.84; p ≤ 0.01).
#57 “Poor communication”
#58 “Inability to communicate effectively”
#59 “Lack of communication”
#60 “Communication breakdown”
#61 “Poor communication skills”
Overconfidence. A “know-it-all” attitude or feeling of being overconfident about one’s clinical skills was also identified as one the factors that may contribute to errors in pre-hospital care, as shown by quotes #62–#64.
#62 “Over confidence”
#63 “Knowing it all”
#64 “Be over confident”
Poor leadership and management practices. Participants, furthermore, reported that a lack of good leadership and management practices at an emergency scene could contribute to errors during pre-hospital care, as highlighted by quotes #65–#68.
#65 “Poor Leadership Practices”
#66 “Poor Management Practice”
#67 “Without clear leadership or direction”
#68 “Collapse of the chain of command…”
Intimidation by and pressure from senior colleagues. Lastly, participants were of the opinion that intimidation by and pressure from senior colleagues can also precipitate human error during pre-hospital emergency care (cf. Quotes #69–#80).
#69 “Pressure from Superiors to meet timelines”
#70 “Fear of higher qualified practitioners”
#80 “Intimidation by senior medics”
Factors perceived by participants as influencing patient safety in the pre-hospital emergency care setting
In this section of the questionnaire, participants were asked to list factors that, in their own opinion, influence patient safety in the pre-hospital emergency care setting. Analysis of participants’ responses generated six dominant themes, as shown in Fig. 1. According to participants, inadequate equipment, environmental factors, personal safety concerns and practitioners’ incompetence are the top four influencers of patient safety in the pre-hospital emergency care setting.
Organizational culture and attitudes about patient safety and human error in the pre-hospital care setting