title: Understanding safety in prehospital emergency medical services for children.
abstract: OBJECTIVE
  For over a decade, the field of medicine has recognized the importance of studying and designing strategies to prevent safety issues in hospitals and clinics. However, there has been less focus on understanding safety in prehospital emergency medical services (EMS), particularly in regard to children. Roughly 27.7 million (or 27%) of the annual emergency department visits are by children under the age of 19, and about 2 million of these children reach the hospital via EMS. This paper adds to our qualitative understanding of the nature and contributors to safety events in the prehospital emergency care of children.
  
  
  METHODS
  We conducted four 8- to 12-person focus groups among paid and volunteer EMS providers to understand 1) patient safety issues that occur in the prehospital care of children, and 2) factors that contribute to these safety issues (e.g., patient, family, systems, environmental, or individual provider factors). Focus groups were conducted in rural and urban settings. Interview transcripts were coded for overarching themes.
  
  
  RESULTS
  Key factors and themes identified in the analysis were grouped into categories using an ecological approach that distinguishes between systems, team, child and family, and individual provider level contributors. At the systems level, focus group participants cited challenges such as lack of appropriately sized equipment or standardized pediatric medication dosages, insufficient human resources, limited pediatric training and experience, and aspects of emergency medical services culture. EMS team level factors centered on communication with other EMS providers (both prehospital and hospital). Family and child factors included communication barriers and challenging clinical situations or scene characteristics. Finally, focus group participants highlighted a range of provider level factors, including heightened levels of anxiety, insufficient experience and training with children, and errors in assessment and decision making.
  
  
  CONCLUSIONS
  The findings of our study suggest that, just as in hospital medicine, factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements. Future studies are needed to ascertain the generalizability of these findings and further refine the underlying mechanisms.
authors.forename: Erika K
authors.initials: EK
authors.lastname: Cottrell
authors.forename: Kerth
authors.initials: K
authors.lastname: O'Brien
authors.forename: Merlin
authors.initials: M
authors.lastname: Curry
authors.forename: Garth D
authors.initials: GD
authors.lastname: Meckler
authors.forename: Philip P
authors.initials: PP
authors.lastname: Engle
authors.forename: Jonathan
authors.initials: J
authors.lastname: Jui
authors.forename: Caitlin
authors.initials: C
authors.lastname: Summers
authors.forename: William
authors.initials: W
authors.lastname: Lambert
authors.forename: Jeanne-Marie
authors.initials: JM
authors.lastname: Guise
mesh_terms: D002648:Child; D002675:Child, Preschool; D032882:Comprehension; D004630:Emergencies; D004632:Emergency Medical Services / Q000592:standards* / Q000639:trends; D005260:Female; D017144:Focus Groups / Q000379:methods*; D006302:Health Services Research; D006801:Humans; D008297:Male; D009922:Oregon; D005791:Patient Care / Q000592:standards / Q000639:trends; D061214:Patient Safety; D011785:Quality Assurance, Health Care; D018570:Risk Assessment
keywords: child health services; delivery of care; emergency medicine; health services research; safety