[Emergency mission documentation in simulated care. Video-based error analysis].

Area of Science:

• Emergency Medicine
• Medical Documentation
• Quality Improvement

Context:

• Physician-staffed emergency medical services (EMS) play a critical role in pre-hospital care.
• Accurate documentation of on-site care is essential for continuity of care and patient safety.
• Current documentation practices in EMS require thorough evaluation.

Purpose:

• To evaluate the quality of documentation by EMS physicians during simulated critical care scenarios.
• To compare the documented patient records with the actual on-site care provided.
• To identify specific areas of deficiency in EMS physician documentation.

Summary:

• Two simulated scenarios (STEMI and major trauma) were used with 29 EMS teams.
• Analysis revealed substantial inaccuracies and omissions in documenting actions (e.g., 20-25% incorrect/missing) and medications (e.g., 22-23% incorrect/missing).
• Specific parameters like 12-lead ECG and capnometry showed frequent documentation errors, while others like initial blood pressure were mostly accurate.

Impact:

• Suboptimal documentation quality in EMS can compromise patient safety by hindering accurate data transmission to hospitals.
• There is a clear need to enhance EMS documentation through strategies like electronic health records, targeted training, and quality management.
• Further research is recommended due to the study's small sample size to validate these findings.