Mislabeled out-of-hospital patient care records during transitions of care: a quality improvement intervention using root cause analysis (RCA) in an EMS system
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0000-0002-4864-3705 Date
2025-06-30
Journal Title
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Publisher
Towarzystwo Pomocy Doraźnej
Abstract
INTRODUCTION: Out-of-hospital emergency care has developed dramatically and grown more complex in the last decade. Transfer of care between out-of-hospital clinicians and the emergency department (ED) staff drives the connection to the healthcare system. Across the US, this process is highly variable and not standardized, which may lead to adverse events. The purpose of this quality study is to identify the cause of mislabeled EMS patient care reports in an EMS agency and develop an intervention to reduce the rate of mislabeled patient care reports. MATERIALS AND METHODS: This quality improvement study follows the model for improvement process, using PDCA cycles and root cause analysis, and used the two-sample unmatched Wilcoxon rank-sum to test for differences in the number of mislabeled records after intervention implementation. RESULTS: Before the intervention, the receiving facilities identified a total of 75 mislabeled ePCR. After implementation of the facility code changes, the receiving facilities identified a reduction in the number of mislabeled ePCRs received from Agency E, from 37 in January to 14 in April. This change represents a 37.83% (z=-10.583, p=0.000) reduction in the number of mislabeled ePCRs, although the EMS Agency E still accounts for the largest proportion of mislabeled records with more than 70%, even after the intervention. CONCLUSIONS: A considerable number of mislabeled records (65%) remain unexplained by the technological factors identified in the PDCA Root Cause Analysis approach. Other factors, including human factors and other technological factors not addressed in this study, which may require validation rules, may still be contributing to mislabeled EMS records.