Managing Risk in Ambulance Practice

Risk exists in every aspect of business, and the way organisations manage this risk will determine how it will affect the organisation’s ability to achieve or exceed its objectives. The objective of an ambulance service is to provide emergency medical treatment and transport to patients within the community. The environment in which paramedics strive to achieve these objectives is dynamic, often hazardous and full of risk. Surprisingly, current paramedic education and training incorporates very little training if any at all, in the area of risk management. This paper will review the current knowledge base on the topic of risk management in ambulance practice. It will then develop a set of guidelines for applying the AS/NZS ISO 31000 Risk Management Standards to ambulance practice in order to equip paramedics with a greater understanding and application of risk management practices. 

It has been well acknowledged that risk exists in all aspects of our lives, in all industries, at home, socially, and in economics (AS/NZS 2009, p. iv; IRM 2011, p. 1). Paramedics provide emergency medical services in an emergency environment that is, by definition, hazardous and potentially full of risk. Given that this is the case, it is surprising to find that little is known about the way paramedics manage this risk. 

I have worked as a paramedic in both the Metropolitan Ambulance Service of Victoria and the Ambulance Service of NSW (ASNSW). It has been observed that although so much time is spent training and educating paramedics on areas such as anatomy and physiology, emergency medical procedures and communication, there is very little training in the area of risk management. Where some training has been provided, it has often been in the area of personal protective equipment (PPE), as a means of meeting legislative OH&S requirements, rather than providing an understanding of risk management concepts in a whole.

To achieve successful risk management in ambulance practice, paramedics must develop a culture of risk management that is incorporated into every aspect of their work, rather than meeting basic legislative requirements under work-cover law. 

Hypothesis  

Risk in ambulance practice can be better managed by equipping paramedics with training and education in risk management and the development of a risk management culture. 

Paramedics work in a unique and often uncontrolled environment in which risk in its many levels is ubiquitous. Given that this is the case, paramedics need to be equipped with a strong risk management knowledge and culture, so that they are able to achieve their objectives. The aim of this paper is to determine the current knowledge base on the topic of risk management in ambulance practice and then to develop a set of guidelines for applying the AS/NZS ISO 31000:2009 Risk Management Standards to ambulance practice. 

What is risk?

The term ‘risk’ can be defined as the ‘effects of uncertainty on objectives’ (AS/NZS 2009, p. 1). Risk exists in every aspect of society. It is impossible to achieve any goal without the existence of risk. Everything we do entails a certain level of risk that we will or will not achieve our objectives, or that we will exceed the goals of our objectives.

Risk can be further identified as the relationship between the likelihood of an event and the consequence if that event occurs. For example, there is a high likelihood that a paramedic will get a common cold and not be able to attend work for a couple days during some stage of the year; however, the consequence of such an event has only a minor effect on the objectives of the organisation. Alternatively, the likelihood of a paramedic getting meningococcal meningitis is very low; while the consequence of a paramedic getting meningococcal meningitis from a patient is severe and potentially fatal. 

All organisations are potentially influenced by both external and internal factors that have an effect on whether, when and the extent to which they will achieve or exceed their objectives. The effect this uncertainty has on the organisation’s objectives is ‘risk.’

In ambulance practice risk can be further defined as the effects of uncertainty on a paramedic’s ability to provide emergency medical treatment and transport to a patient during an emergency. If an ambulance develops a mechanical fault enroute to an emergency, the risk exists that an ambulance will no longer be able to attend the emergency. Now, if there is a second ambulance nearby that is able to respond to the emergency, the consequence of this event is not severe; however, if there is no other ambulance in the area then the consequence of this risk is potentially high.

Risk Management

The term ‘risk management’ can be defined as any process whereby a person or organisation attempts to change the likelihood or consequence of a possible event. People have been instinctively managing risk for thousands of years. In early evolutionary history, people found that they were able to manage the risk of freezing to death by covering their skin with leaves, animal hide and huddling together (Bernstein 1998, pp. 15-16). Since the 1950s many businesses have utilised risk management strategies to mitigate the potential risk their businesses face (IRM 2011, p.18). Even in general society today, we manage risk. When we get into a car, there is the risk that we may have a motor vehicle crash, so we put our seatbelt on to reduce the consequence of this and we drive cars with anti-brake-locking (ABS) braking systems to reduce the likelihood of having an accident. If the car develops a flat tyre, we have a spare tyre available to replace the first one, so that our original objective (to get from point A to point B) is not compromised. These are all attempts to manage risk through the active process of risk management.

Although risk management has been around a long time, it should be acknowledged that formal frameworks for the risk management process are a relatively new concept that only started to advance into formalised frameworks in the early 1990s. One such advancement occurred in 1995 when the AS 4360: 1995 developed a framework that clearly outlined the main processes of risk management in a standardised form. These frameworks have been regularly updated to meet the evolving needs of risk management. The most current version of this is the AS/NZS ISO 31000:2009 Risk Management Standards (AS/NZS 31000:2009, p.1).

In the United Kingdom, the Institute of Risk Management developed a similar standard and generic framework for the risk management process in 2002. This standard was made readily available to all persons for free over the internet. The organisation identified that risk management is in the interests of all persons and should be available to all (IRM 2011, p. 4). 

The AS/NZS ISO 31000 (2009) has described risk management as a set of ‘coordinated activities to direct and control an organisation with regard to risk’ (AS/NZS ISO 31000 2009, p.2). Organisations manage their relationship with risk by anticipating it, developing an understanding of it and deciding whether or not to modify it. Throughout this process they communicate and consult with stakeholders and monitor and review the risk and the controls that are modifying the risk. The AS/NZS ISO 31000:2009 describes one systematic and logical process for doing this in detail.

The AS/NZS ISO 31000: 2009 Risk Management Standards

The AS/NZS ISO 31000:2009 Risk Management Standards is a set of standards in risk management that was prepared by the Joint Standards Australia/Standards New Zealand Committee on Risk Management in order to provide a generic framework for managing risk. These Standards are not part of government, and are not laws, regulations or legal documents. Because of their rigour, they are often called up into legislation by government and often become mandatory. When this occurs, it is a decision made by the elected government and not by Standards. 

The AS/NZS ISO 31000:2009 recommends that organisations should have a framework that integrates the process for managing risk into the organisation’s overall governance, strategy and planning, management, reporting processes, policies, values and culture.

The AS/NZS ISO 31000: 2009 identifies the following framework of processes in risk management:

• Establishing the context
• Risk identification
• Risk analysis
• Risk evaluation; and
• Risk treatment

(AS/NZS 2009, p. 14).

 Throughout this entire process, the risk management committee, key stakeholders, management, and front-line employees should maintain a regular process of communication and consultation, as well as monitoring and review as a continuous process throughout.

The Paramedic Environment  

Paramedics provide emergency medical services in physically hazardous and socially complex situations where risks are often difficult to foresee and mitigate (Campeau 2008, p.3). Paramedics respond to emergency sites, in which potential risks are endless. Rendell and Johnson (2004) identify that: ‘every situation that an EMS (paramedic) enters into carries with it a certain amount of associated risk (p.3).’

For example: a car that has crashed and rolled over may have broken glass, leaking fuel, fallen live power lines down, the potential for other vehicles to crash into it, and blood. In addition to this, there are many dangers associated with using hydraulic pressure equipment to access the patient in the car, combined with loud noises, multiple distractions and subsequently poor communication amongst emergency workers. Throughout this, a paramedic must be able to rapidly sieve out the acceptable or unacceptable risks on the scene and then implement specific risk treatment options in order to safely access the patients and provide medical assistance. 

Given that this is the case, it is surprising that many ambulance services within Australia and globally, appear to place little emphasis on the study of and practice of paramedic risk management (Campeau 2008, p. 5). These work settings provide unique challenges in terms of managing resources in order to enable the delivery of emergency patient care in a relatively safe way. Although paramedics work in this environment full of risk, the concept of risk management in ambulance practice is relatively new and there is only limited training provided for paramedics on this topic. Where training is provided, it is often in the form of basic Occupational Health and Safety (OH&S) policies which meet legislative requirements of the ambulance service they work within (Levick 2008, p. 18). Where Risk Management is incorporated into an organisation, it is only in senior management and rarely relates to front-line employees in both the development of practice and the introduction of concepts/training. 

Once a risk is identified, analysed and evaluated in the Ambulance Service, during the process of risk management, the risk treatment process looks to reduce the likelihood or consequence of the event, transfer ownership of the risk or avoid it altogether. Parker (2002) recognises that: ‘for paramedics, emergencies are routine and the unexpected the norm’ (p.2). This dynamic and unpredictable environment that paramedics are exposed to during their normal working practices increases their potential exposure to risk. As a result of this, any successful risk management policy implemented for paramedics, require a strong focus on the front-line employees (paramedics) to develop a culture of risk management. 

Campeau (2008) has developed one theory of how paramedics manage risk and identifies that  “paramedics strive to control their working ‘space’ in order to manage a scene; in doing this, a paramedic can shape what looks like a disaster site, into a safe, comfortable, working environment (p.4).” It has also been acknowledged that for a paramedic to develop this ability takes years of experience and currently has not been taught to paramedics didactically.  

Risk in Ambulance Practice 

Risks in ambulance practice can be clearly divided into the following areas: 

• People risks
• Organisational environment risks
• Organisational management risks (business continuity)
• Ambulance practice specific risks

Within these categories, paramedics must manage risks that occur in the following activities of their occupation:

Responding to an emergency;

• Attending to a patient at the scene of an emergency;
• Driving to hospital
• Failure to respond an Ambulance to an Emergency
• Driving an Ambulance during emergency procedures and (lights and sirens)
• Parking an Ambulance at an Emergency
• Interacting with other Emergency Personnel at an Emergency
• Treating patients at an Emergency
• Violence towards Paramedics
• Transporting patients to a Hospital
• Fatigue
• Failure to maintain competent and up-to-date with Ambulance Practices
• General Wellbeing of the Paramedic
• Promoting an image of duty, competence and compassion to the community

It should be noted that risk identification is a potentially limitless function of a paramedic’s duty, and these are not the only risks that need to be identified in ambulance practice.

Why Should Ambulance Services Manage Risk?

By managing risks, Ambulance Services are able to: 

• Achieve their objectives better
• Decrease the cost of unforseen events
• Decrease the consequence of adverse events
• Improve paramedics’ health and wellbeing
• Improve patient health outcomes
• Provide more cost effective ambulance services to the community