leg belts, or slowing/ stopping the ambulance to enable provision of safe clinical care). OSJ Patient Transfer ambulance attended 2 Review concluded that New helicopter dispatch Review of dispatch criteria of patient with traumatic injury. Back up communication procedure due for release April helicopter resources. requested but unavailable locally. A between specialist 2014 to assist with clarity of helicopter was available but was roles within the dispatch criteria. cancelled by Communication Centre communication centre Proposed organisational due to falling outside of dispatch should be improved. change will provide additional guidelines. Patient Transfer ambulance training and quality transported patient to hospital without improvement should enhance access to appropriate splinting and communication between analgesia. specialist roles in the communication centres. Subsequent appointment of Clinical Manager to assist in clinical oversight. Equipment-related events # Provider Summary of Reportable Root Cause Analysis Recommendations Action Taken Event OSJ Patient in cardiac arrest, 1 Proper operation of the defibrillator was To ensure that operator error was not Developmental defibrillator would not display confirmed during functional and a factor, developmental support support provided. cardiac rhythm. Resuscitation performance testing by the manufacturer. provided to clinically support practice. continued. The reported issue was not duplicated. Patient did not survive. Coroner ruled that the failure of the defibrillator did not affect the outcome for the patient. Other events # Provider Summary of Reportable Event Root Cause Analysis Recommendations Action Taken 1 WFA Ambulance redirected when patient Call-taker error Communications Centre processes be reviewed, Corrective seemed to improve during call-taking. including staff training, and explore possibility of training Ambulance arrival delayed by 24/7 Clinical Desk. completed approximately 24 minutes 2 WFA Paramedic response to incident Limited training Additional training provided. Training response led to identification of specific opportunities and little completed training needs (no patient harm clinical supervision while involved). working for previous employer.
leg belts, or slowing/ stopping the ambulance to enable provision of safe clinical care). 2 OSJ Patient Transfer ambulance attended patient with traumatic injury. Back up requested but unavailable locally. A helicopter was available but was cancelled by Communication Centre due to falling outside of dispatch guidelines. Patient Transfer ambulance transported patient to hospital without access to appropriate splinting and analgesia. Review concluded that communication between specialist roles within the communication centre should be improved. New helicopter dispatch procedure due for release April 2014 to assist with clarity of dispatch criteria. Proposed organisational change will provide additional training and quality improvement should enhance communication between specialist roles in the communication centres. Subsequent appointment of Clinical Manager to assist in clinical oversight. Review of dispatch criteria of helicopter resources. Equipment-related events # Provider Summary of Reportable Event Root Cause Analysis Recommendations Action Taken 1 OSJ Patient in cardiac arrest, defibrillator would not display cardiac rhythm. Resuscitation continued. Patient did not survive. Proper operation of the defibrillator was confirmed during functional and performance testing by the manufacturer. The reported issue was not duplicated. Coroner ruled that the failure of the defibrillator did not affect the outcome for the patient. To ensure that operator error was not a factor, developmental support provided to clinically support practice. Developmental support provided. Other events # Provider Summary of Reportable Event Root Cause Analysis Recommendations Action Taken 1 WFA Ambulance redirected when patient seemed to improve during call-taking. Ambulance arrival delayed by approximately 24 minutes Call-taker error Communications Centre processes be reviewed, including staff training, and explore possibility of 24/7 Clinical Desk. Corrective training completed 2 WFA Paramedic response to incident response led to identification of specific training needs (no patient harm involved). Limited training opportunities and little clinical supervision while working for previous employer. Additional training provided. Training completed
summary-reportable-events-stjohn-wfa-jan-mar-2014.docx