Delphi Consensus on Never Events in Emergency Medical Services – NEEMS-1-Study

Delphi Consensus on Never Events in Emergency Medical Services – NEEMS-1-Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delphi Consensus on Never Events in Emergency Medical Services – NEEMS-1-Study Hartwig MARUNG, Reinhard STRAMETZ, Carla NAU, Matthias LENZ, Stefan POLOCZEK, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6908453/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Prehospital emergency care is often conducted under challenging and unpredictable conditions, creating a high-risk environment for both patients and healthcare professionals. Despite its significance, the topic of safety has historically received limited attention in rescue sciences. Our study aimed to develop a consensus-based set of safety indicators for Emergency Medical Services (EMS). To achieve this, we adapted the "Never Event" concept - widely established in clinical settings in the United States and the United Kingdom over the past decade - to the context of prehospital emergency care. Methods A three-round web-based Delphi process was conducted in 2014 among experts in the field of emergency care to achieve consensus on Never Events specific to the prehospital environment. Primary outcome was the mean rating of item relevance on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Statements were considered consensual if they achieved a mean rating of ≥ 3.75 in rounds 1 and 2, and ≥ 2.5 in round 3. Results A total of 83 experts participated in round 1, with 68 completing rounds 2 and 3. The highest levels of agreement were reached for the following statements: “Patient death or serious disability associated with an airway management error”, “Omission of telephone-assisted CPR instructions despite identification of cardiac arrest and availability of trained personnel”, and “Patient death or serious disability associated with a medication error”. Overall, 32 events were regarded by the expert panel as “preventable by all means”. Conclusion Given the extensive list of 32 events, reaching the aforementioned study goal appeared to be doubtful. Further research is mandatory to establish broad expert consensus on Never Events in EMS. Figures Figure 1 Figure 2 BACKGROUND Prehospital emergency care is often characterised by pressure of time, a lack of information regarding patient history and medication, external conditions (e.g. weather, space, light) and challenging time of day. All these factors create a high-risk environment for patients, employees and third parties alike. Although this conclusion is rather obvious, academic emergency medicine has given relatively little attention to safety issues in the past. Owing to massive efforts during the last three decades, guidelines for relevant medical conditions, such as cardiopulmonary resuscitation (CPR), are currently issued and implemented worldwide. However, a widely accepted consensus on best practices for effective safety measures has not yet been established. Our study aimed to develop a consensus of this sort on safety management in EMS. For this purpose, we converted the Never Event concept, which has been used broadly in clinical medicine in the United States and Great Britain for more than a decade, to the prehospital emergency setting [ 1 , 2 ] and initiated a Delphi survey among experts in the fields of prehospital emergency training, management and science. The results of the first three rounds of that survey have been published as an abstract [ 3 ]. METHODS General selection criteria and literature base Initially, we conducted a comprehensive literature review for the years 2005 to 2014 in PubMed, the world`s leading medical data bank, as well as Google Scholar, using the key words “Never Events”, “serious reportable events”, “Emergency Medical Services”, “prehospital emergency care”, “patient safety”, “risk management”, “human error”, “adverse event” and “critical event” to generate a catalogue of potential Never Events that should be included in our study. In accordance with the criteria developed by the National Quality Forum in the United States in 2011, these events had to be serious, largely preventable, adverse and reportable to be eligible for our consensus procedure [ 1 ]. Database for individual items The following three examples show the rationale behind the items on the list of Round 1 (Figure 1). Delphi technique A web-based Delphi consensus study was undertaken to gain expert consensus on the catalogue of Never Events. The Delphi technique is a step-by-step process comprising a predefined number of anonymous voting rounds in which experts do not necessarily meet in person [ 8 – 10 ]. Its main goal is to establish a consensus on specific controversial issues. Anonymous procedures, such as web-based Delphi surveys, remove financial and geographical constraints that experts must address to meet in person. In addition, they reduce the inadequate impact that single influential participants may have on the rest of the participants [ 6 ]. Moreover, when experts do not meet face-to-face, the opportunity for discussion is limited. Thus, survey instruments should include forums allowing participants to comment on controversial issues. Experts had to vote on statements initially proposed by the investigators based on the abovementioned literature review and selection process; this voting was statistically evaluated. Items that did not reach the 75% consensus threshold were either discarded or modified and reintroduced into the survey. The items were modified by applying qualitative content analysis of expert comments. Recruitment of experts A purposive sampling technique was used to obtain a true representation of experts in the field of emergency medicine in Germany, Austria and the German speaking parts of Switzerland. Experts were eligible if they were either EMS Medical Directors or researchers in the field of prehospital emergency care or managers of EMS education and training facilities in Germany, Austria, or Switzerland. Potential participants were identified via a comprehensive web-based search, during which a total of 150 experts were identified and contacted. Among these, 137 were from Germany, nine from Austria and four from Switzerland. Baseline data defining expert status were retrieved after a participant had inscribed into the survey platform. If the criterion for eligibility as an expert was not confirmed during this step, the individual data collection process was stopped automatically by the survey tool. Only experts who had completed a voting round were invited to participate in the consecutive round. Administration of the survey Rounds 1 to 3 The survey was administered online via a widely used survey application ( www.surveymonkey.com ). Round One started in June 2014, and round Three was completed in November 2014. Each expert was invited personally via email, including a hyperlink to the online questionnaire. Participation was voluntary, and financial or other incentives were not offered. The NEEMS-1-questionnaire and the invitation letter are available online as supplementary materials for this study. At the beginning of the first round, participants were provided with pieces of information as follows: 1) definition of the term “Never Events” as “events in the context of emergency care that should never occur, i.e., adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable; 2) a brief description of how the baseline Never Event catalogue had been developed 3) methodology and schedule of the Delphi procedure; and 4) specific features of the first round. The experts were asked to rank the relevance of each event on a 5-point Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”). Completing the vote for every statement was mandatory. All the experts were explicitly asked to give their comments on each statement and the information issued with it. For this purpose, free text boxes were provided at the end of each statement. After finishing rounds 1 and 2, respectively, each expert had the opportunity to propose additional statements. The participants were asked to respond within two weeks and were sent a reminder email one week and two days before the deadline day. The interim results of the voting process were presented to participants at the beginning of rounds 2 and 3, including the mean scores for each statement. Statements on the threshold to the predetermined acceptance criteria were highlighted via the original statement, expert comments, and the proposed modification of the statement. All the comments were anonymized. This was intended to encourage reflection at the beginning of each round of votes. The survey was repeated three times until consensus according to the predefined criteria had been reached or an item had been rejected. Data analysis and definition of consensus: Rounds 1 to 3 We calculated the mean ranking for each statement. For the first and second rounds, we used a consensus threshold of 75%, i.e., statements with a mean of 3.75 or greater were defined as “consented”. The remaining statements were either discarded or modified based on expert comments. For the final round, the consensus threshold was 50%, i.e., statements with a mean of 2.5 or greater were defined as “consented”. Statements with a mean of less than 2.5 were discarded. Results Eighty-three experts participated in round 1, and 68 experts completed rounds 2 and 3 (Fig. 2 ). For demographic data of the Delphi panel see Table 1 . Table 1 Demographic data of the Delphi panel % (n) Sex female 4.8 (4) male 95.2 (79) Age 26–35 2.4 (2) 36–45 33.7 (28) 46–55 45.8 (38) 56–65 15.7 (13) > 65 2.4 (2) Professional background Emergency Physician 83.1 (69) Paramedic 14.5 (12) Other 2.4 (2) Professional Experience 5–10 years > 10 years 8.4 (7) 91.6 (76) Additional Qualifications EMS Medical Director 53.0 (44) Research Activities in Emergency Medicine 44.5 (37) EMS teacher/ instructor 26.5 (22) Mass Casualty Expert 18.1 (15) Membership in Professional Organisations (Multiple answers permitted) n = 158 (1.9 per capita) 27 initial statements addressing Never Events were proposed after literature review and adaption to the criteria developed by the National Quality Forum in the United States in 2011. In rounds 1 to 3, a total of 24 items exhibited an approval rate of 75% or more, with eight items of more than 50%; only one item was not approved as a Never event during the consensus process (Table 2 ). Another six statements were proposed by the experts during rounds 1 and 2. Table 2 Ranking of the NEVER Items Rounds 1 to 3 Item Round 1 Mean (n = 80) Round 2 Mean (n = 68) Round 3 Mean (n = 68) No. of expert comments total/per round No. of modifications * Relevant Rating Mean Accepted as Never Event Approval rate > 75% (rating > 3,75) Patient death or serious disability associated with an airway management error 4,89 - - 12/12 none 4,89 yes Omission of telephone assisted CPR instructions despite identification of cardiac arrest and availability of trained personnel 4,59 - - 12/12 none 4,59 yes Patient death or serious disability associated with a medication error 4,55 - - 12/12 none 4,55 yes Transport to medical facility unqualified for required treatment 4,51 - - 10/10 none 4,51 yes Death or serious disability of an infant associated with inadequate therapy 4,46 - - 12/12 none 4,46 yes Patient death or serious disability associated with inadequate education and training ⌂ - 4,38 - 12/12 none 4,38 yes Patient death or serious disability associated with inadequate handling of medical products (respirator, defibrillator etc.) 4,28 - - 9/9 none 4,28 yes Inadequate postmortem examination (declaration of death despite presence of vital signs) 4,26 - - 15/15 none 4,26 yes Patient death or serious disability associated with unavailability of an emergency unit 3,71 4,25 - 30/15 1 4,25 yes Patient death or serious disability associated with undertreatment ⌂ - 4,23 - 9/9 none 4,23 yes Patient death or serious disability associated with overtreatment ⌂ - 4,21 - 8/8 none 4,21 yes Patient death or serious disability associated with failure to render assistance on part of EMS personnel 4,19 - - 10/10 none 4,19 yes Patient death or serious disability associated with hypoglycaemia 4,13 - - 12/12 none 4,13 yes Severe violation of privacy or professional secrecy (e.g., handing out EMS photographs or videos to the media) 4,04 - - 13/13 none 4,04 yes Patient death or serious disability associated with the use of restraints while being cared for by EMS 3,33 4,03 - 16/8 1 4,03 yes Patient death or serious disability associated with refusal of transport by a patient lacking capacity of consent 4,01 - - 16/16 none 4,01 yes Patient death or serious disability associated with inadequate patient data management ⌂ - 4,00 - 3/3 none 4,00 yes Patient death or serious disability associated with inadequate immobilisation 3,76 3,99 - 20/10 1 3,99 yes Patient or employee death or serious disability associated with transport using red light and siren 3,99 - - 12/12 none 3,99 yes Patient or employee death or serious disability associated with massive violation of Work Hours Act ⌂ - 3,65 3,87 18/9 1 3,87 yes Patient death or serious disability associated with inadequate fixation of EMS equipment during transport 3,86 - - 9/9 none 3,86 yes Employee death or serious disability associated with lack or inadequate use of protective gear 3,86 - - 9/9 none 3,86 yes Sexual assault on a patient at any time during an EMS mission 3,33 3,67 3,82 32/10,67 2 3,82 yes Patient death or serious disability associated with failure to alert special units (helicopter, divers, rescue from heights) 3,81 - - 14/14 none 3,81 yes Approval rate > 50% (relevant rating > 2.5 and < 3.75) Any instance of care ordered by or provided by someone impersonating a physician or EMT/paramedic 3,05 3,57 3,67 25/8,33 none 3,67 yes Death or serious disability of a patient, employee or third party associated with inadequately managed critical incidents ⌂ - 3,94 3,63 17/8,5 1 3,63 yes Patient death or serious disability associated with a burn incurred from any source while being cared for by EMS 2,85 3,37 3,57 30/10 2 3,57 yes Patient death or serious disability associated with minor injuries according to triage in a mass casualty incident 3,55 3,79 3,54 33/11 2 3,54 yes Patient death or serious disability associated with invasive procedures 3,49 3,93 3,53 42/14 1 3,53 yes Prehospital or immediately post-handover death in an NACA I-III class patient 3,42 4,00 3,15 43/14,33 2 3,15 yes Pressure ulcers immediately acquired during an EMS mission 3,34 3,50 3,07 27/9 2 3,07 yes Death or significant injury of a patient or staff member resulting from a physical assault at any time during an EMS mission 3,38 3,49 2,88 33/11 1 2,88 yes Not approved (relevant rating < 2.5) Patient death or serious disability associated with patient elopement (disappearance) during an EMS mission 2,57 3,09 2,24 31/10,33 1 2,24 no ⌂ Additional items suggested by experts during rounds 1 and 2 * based on expert feedback from rounds 1 and 2 Discussion In this study, we introduce a Delphi approach for achieving basic consensus on patient safety in EMS. The Delphi method is widely used in health research to establish best practices via joint expertise in fields where evidence is limited or inconsistent [ 8 – 10 ]. However, the process quality of Delphi studies is frequently unclear because of a lack of standardised reporting. Nasa et al. recently proposed nine systematic quality tools for evaluating the Delphi methodology, including identification of the problem area of research, selection of the expert panel, anonymity of panellists, controlled feedback, iterative Delphi rounds, consensus criteria, analysis of consensus, closing criteria, and stability of the results [ 11 ]. In the conception and presentation of this study, we aimed to take these tools into account. As a result of our survey, 32 out of 33 items were regarded by EMS experts to be serious, largely preventable, adverse and reportable and thus fulfilled the US National Quality Forum’s (NFQ) criteria for Never Events [ 1 ]. The items receiving the highest levels of consent were “Patient death or serious disability associated with an airway management error” (4.89 rating), “Omission of telephone-assisted CPR instructions despite identification of cardiac arrest and availability of trained personnel” (4.59) and “Patient death or serious disability associated with a medication error” (4.55). At the time of our survey, however, those three incidents were anything but rare. Airway management errors were a serious issue in 2014 and continue to be a threat to patient safety. In 2007, a New York study group reported an 8.3% rate of unrecognised esophageal intubation and a 20% rate of right mainstem intubation. Only one patient survived to discharge [ 12 ]. In the same year, Timmermann et al. reported undetected esophageal intubation in 10 out of 150 patients (6.7%), seven of whom died within the first 24 hours after beginning treatment [ 4 ]. These findings occurred despite clear evidence that the use of continuous end-tidal carbon dioxide monitoring can effectively reduce the rate of unrecognised misplaced intubations in the EMS to zero [ 13 ]. After bundles of safety measures for prehospital airway management have been implemented in many EMS systems, the rates of catastrophic errors seem to decrease. This assumption is supported by a recent study from a German helicopter-based EMS showing a 1.2% rate of unrecognised esophageal intubation, i.e., an 80% decrease compared with that reported in the study by Timmermann et al. [ 14 ]. Nevertheless, those errors pose a persistent threat to patient safety in EMS. Tackling the problem of nonprovision of dispatcher assisted CPR (DA-CPR) instructions seems even more challenging, as DA-CPR rates in central Europe were as low as 22.5% at the time of our first Delphi study [ 15 ]. This is true although CPR guidelines worldwide have advocated the use of DA-CPR since 2010 [ 16 ]. According to the EURECA TWO study from the year 2020, the median rate of DA-CPR was still only 37.3%, ranging from 3.2–87.8% [ 17 ]. Severe harm resulting from a medication error may be difficult to identify. Nevertheless, a small number of studies have addressed that issue by the year 2014, and Delphi experts have classified patient death or serious disability resulting from those events as fully preventable [ 18 , 19 ]. Eight years after our study, a 2022 study from Doha reported a 4.3% rate of adverse events among 3475 EMS patient records. These findings imply that re-evaluating medication errors as largely preventable may be necessary [ 20 ]. The fact that the experts consented almost all items proposed as Never Events, although some are quite common in everyday practice, is a dilemma and may have various reasons: The fact that events occur regularly that experts consider as potentially dangerous and preventable might indeed represent a serious challenge that prehospital emergency care is facing. However, the problem could be due to the methodology of this study, i.e., experts may not have been informed precisely enough when to define an item as a Never Event, or the threshold for consensus may have been too low. Limitations In Delphi consensus, wording is a critical issue. Thus, only experts from the German speaking countries Germany, Austria and Switzerland were invited, so that transferring the results to EMS systems worldwide may be difficult. Also, with an extensive list of 32 events deemed preventable by all means, reaching our study goal seems doubtful. In addition, the study was performed in the year 2014. Hence, further research is necessary prior to the publication of a practically applicable catalogue of Never Events. Conclusion The topics of patient and employee safety in the prehospital emergency environment have received some attention in the past, but until today, there is a lack of robust evidence and best practice recommendations [ 21 ]. The Never Event approach may prove valuable with respect to establishing a safety culture in EMS. Because criteria for Never Events have been redefined over the past decade, a follow-op Delphi process entitled NEEMS-2-Study was undertaken in November and December 2024 to generate a more concise and practical list of Never Events for prehospital emergency care settings. The results of this study will be published promptly. Declarations Competing interests: The authors declare no competing interests. Prior Presentations: None Funding Sources/Disclosures: None Human Ethics declaration: Ethical review and approval were waived for this study after the concept was presented to the ethical committee of the medical faculty of Lubeck University. Availability of Data and Materials: Consent to Participate declaration: Informed consent was obtained from all subjects involved in the study. Consent for Publication declaration: Not applicable. Data Availability Statement The data presented in this study are available upon request from the corresponding author. References National Quality Forum (NQF). Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report. Washington D.C. 2011 https://www.england.nhs.uk/patient-safety/revised-never-events-policy-and-framework/ (last accessed on June 18, 2025) Marung H, Moecke Hp, Poloczek S, Lenz M. Never Events: Building a consensus on Patient Safety in Prehospital Emergency Care. Resuscitation 2015; 86: S122-123 DOI: 10.1016/j.resuscitation.2015.09.290 Timmermann A, Russo SG, Eich C et al. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg 2007; 104: 619–623 DOI: 10.1213/01.ane.0000253523.80050.e9 Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019; 10:2042098618821916. DOI: 10.1177/2042098618821916 Wnent J, Seewald S, Heringlake M et al. Choice of hospital after out-of-hospital cardiac arrest - a decision with far-reaching consequences: a study in a large German city. Crit Care 2012;16: R164. DOI: 10.1186/cc11516 Biewener A, Aschenbrenner U, Rammelt S et al. Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma. 2004;56: 94-8. DOI: 10.1097/01.TA.0000061883.92194.50 Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods characteristics and guidelines for use. Am J Public Health 1984; 74:979e983. DOI: 10.2105/AJPH.74.9.979 Boulkedid R, Abdoul H, Loustau M et al. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS One. 2011;6(6):e20476. DOI: 10.1371/journal.pone.0020476. Graham B, Regehr G, Wright JG. Delphi as a method to establish consensus for diagnostic criteria. J Clin Epidemiol 2003; 56:1150e1156. DOI: 10.1016/s0895-4356(03)00211-7 Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol. 2021; 11:116-129. DOI: 10.5662/wjm.v11.i4.116. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care. 2007; 11:213-8. DOI: 10.1080/10903120701205935. Silvestri S, Ralls GA, Krauss B et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;45:497-503. DOI: 10.1016/j.annemergmed.2004.09.014 Lorenzen U, Marung H, Eimer C et al. Quality and Safety in Prehospital Airway Management – Retrospective Analysis of 18.000 Cases from an Air Rescue Database in Germany. BMC Emerg Med 2024 DOI: 10.1186/s12873-024-01075-x Stipulante S, Tubes R, El Fassi M et al. Implementation of the ALERT algorithm, a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol, in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres. Resuscitation. 2014 Feb;85(2):177-81. DOI: 10.1016/j.resuscitation.2013.10.005. Koster RW, Baubin MA, Bossaert LL et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation. 2010;81(10):1277-92. DOI: 10.1016/j.resuscitation.2010.08.009 Gräsner JT, Wnent J, Herlitz J et al. Survival after out-of-hospital cardiac arrest in Europe-Results of the EuReCa TWO study. Resuscitation 2020, 148 , 218-226. DOI: 10.1016/j.resuscitation.2019.12.042 Kupas DF, Shayhorn MA, Green P, Payton TF. Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors. Prehosp Emerg Care. 2012 Jan-Mar;16(1):67-75. DOI: 10.3109/10903127.2011.621046. Fairbanks RJ, Crittenden CN, O'Gara KG, et al. Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. Acad Emerg Med. 2008 Jul;15(7):633-40. DOI: 10.1111/j.1553-2712.2008.00147.x. Howard I, Howland I, Castle N et al. Retrospective identification of medication related adverse events in the emergency medical services through the analysis of a patient safety register. Sci Rep. 2022; 12:2622. DOI: 10.1038/s41598-022-06290-9. O´ Connor P, O`Malley R, Oglesby AM et al. Measurement and monitoring patient safety in prehospital care: a systematic review. Int J Qual Health Care. 2021;33:mzab013. DOI: 10.1093/intqhc/mzab013. Additional Declarations No competing interests reported. Supplementary Files QuestionnaireNEEMS1Study.pdf NEEMS1StudyInvitationLetter.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6908453","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484723469,"identity":"93eaf2e9-a7f3-4cd9-9155-c1ef4b20cbc0","order_by":0,"name":"Hartwig 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Department","correspondingAuthor":false,"prefix":"","firstName":"Stefan","middleName":"","lastName":"POLOCZEK","suffix":""},{"id":484723474,"identity":"607a81b2-7056-4493-9f4a-c79ced22e523","order_by":5,"name":"Lukas FRITZ","email":"","orcid":"","institution":"MSH Medical School Hamburg","correspondingAuthor":false,"prefix":"","firstName":"Lukas","middleName":"","lastName":"FRITZ","suffix":""},{"id":484723475,"identity":"31d5eb29-51eb-4f54-9792-5a1c24f8548a","order_by":6,"name":"Holger MAURER","email":"","orcid":"","institution":"University Hospital Schleswig-Holstein","correspondingAuthor":false,"prefix":"","firstName":"Holger","middleName":"","lastName":"MAURER","suffix":""}],"badges":[],"createdAt":"2025-06-16 20:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6908453/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6908453/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87031140,"identity":"e0b0eea3-8324-43f6-99c0-0be49ef454a9","added_by":"auto","created_at":"2025-07-18 12:47:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205751,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of example items\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6908453/v1/9d8c4ca4f474e99ad030428f.png"},{"id":87031143,"identity":"81caea33-5d48-4baa-b026-a19e363b9c46","added_by":"auto","created_at":"2025-07-18 12:47:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":230519,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the Delphi consensus process\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6908453/v1/3b1890a539b5f7b4477e00c3.png"},{"id":88756368,"identity":"219205e6-08cb-498c-91eb-67ac50730c08","added_by":"auto","created_at":"2025-08-11 07:17:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1707363,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6908453/v1/b8c0ad72-b236-4cf5-a92d-d81be501555b.pdf"},{"id":87031141,"identity":"42147878-9fdb-4593-aad7-052e5d9533f5","added_by":"auto","created_at":"2025-07-18 12:47:49","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":297548,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireNEEMS1Study.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6908453/v1/15455855bba6a336a8dde6b6.pdf"},{"id":87031146,"identity":"98a4f581-8a02-4079-8396-43889d36502c","added_by":"auto","created_at":"2025-07-18 12:47:50","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":141398,"visible":true,"origin":"","legend":"","description":"","filename":"NEEMS1StudyInvitationLetter.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6908453/v1/4cbe406401b9ade6116a80e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDelphi Consensus on Never Events in Emergency Medical Services – NEEMS-1-Study\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePrehospital emergency care is often characterised by pressure of time, a lack of information regarding patient history and medication, external conditions (e.g. weather, space, light) and challenging time of day. All these factors create a high-risk environment for patients, employees and third parties alike. Although this conclusion is rather obvious, academic emergency medicine has given relatively little attention to safety issues in the past. Owing to massive efforts during the last three decades, guidelines for relevant medical conditions, such as cardiopulmonary resuscitation (CPR), are currently issued and implemented worldwide. However, a widely accepted consensus on best practices for effective safety measures has not yet been established. Our study aimed to develop a consensus of this sort on safety management in EMS. For this purpose, we converted the Never Event concept, which has been used broadly in clinical medicine in the United States and Great Britain for more than a decade, to the prehospital emergency setting [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and initiated a Delphi survey among experts in the fields of prehospital emergency training, management and science. The results of the first three rounds of that survey have been published as an abstract [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eGeneral selection criteria and literature base\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitially, we conducted a comprehensive literature review for the years 2005 to 2014 in PubMed, the world`s leading medical data bank, as well as Google Scholar, using the key words \u0026ldquo;Never Events\u0026rdquo;, \u0026ldquo;serious reportable events\u0026rdquo;, \u0026ldquo;Emergency Medical Services\u0026rdquo;, \u0026ldquo;prehospital emergency care\u0026rdquo;, \u0026ldquo;patient safety\u0026rdquo;, \u0026ldquo;risk management\u0026rdquo;, \u0026ldquo;human error\u0026rdquo;, \u0026ldquo;adverse event\u0026rdquo; and \u0026ldquo;critical event\u0026rdquo; to generate a catalogue of potential Never Events that should be included in our study.\u003c/p\u003e\n\u003cp\u003eIn accordance with the criteria developed by the National Quality Forum in the United States in 2011, these events had to be serious, largely preventable, adverse and reportable to be eligible for our consensus procedure [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDatabase for individual items\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following three examples show the rationale behind the items on the list of Round 1 (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelphi technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA web-based Delphi consensus study was undertaken to gain expert consensus on the catalogue of Never Events. The Delphi technique is a step-by-step process comprising a predefined number of anonymous voting rounds in which experts do not necessarily meet in person [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Its main goal is to establish a consensus on specific controversial issues. Anonymous procedures, such as web-based Delphi surveys, remove financial and geographical constraints that experts must address to meet in person. In addition, they reduce the inadequate impact that single influential participants may have on the rest of the participants [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, when experts do not meet face-to-face, the opportunity for discussion is limited. Thus, survey instruments should include forums allowing participants to comment on controversial issues.\u003c/p\u003e\n\u003cp\u003eExperts had to vote on statements initially proposed by the investigators based on the abovementioned literature review and selection process; this voting was statistically evaluated. Items that did not reach the 75% consensus threshold were either discarded or modified and reintroduced into the survey. The items were modified by applying qualitative content analysis of expert comments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment of experts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA purposive sampling technique was used to obtain a true representation of experts in the field of emergency medicine in Germany, Austria and the German speaking parts of Switzerland. Experts were eligible if they were either EMS Medical Directors or researchers in the field of prehospital emergency care or managers of EMS education and training facilities in Germany, Austria, or Switzerland. Potential participants were identified via a comprehensive web-based search, during which a total of 150 experts were identified and contacted. Among these, 137 were from Germany, nine from Austria and four from Switzerland.\u003c/p\u003e\n\u003cp\u003eBaseline data defining expert status were retrieved after a participant had inscribed into the survey platform. If the criterion for eligibility as an expert was not confirmed during this step, the individual data collection process was stopped automatically by the survey tool. Only experts who had completed a voting round were invited to participate in the consecutive round.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdministration of the survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRounds 1 to 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey was administered online via a widely used survey application (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.surveymonkey.com\u003c/span\u003e\u003c/span\u003e). Round One started in June 2014, and round Three was completed in November 2014. Each expert was invited personally via email, including a hyperlink to the online questionnaire. Participation was voluntary, and financial or other incentives were not offered. The NEEMS-1-questionnaire and the invitation letter are available online as supplementary materials for this study.\u003c/p\u003e\n\u003cp\u003eAt the beginning of the first round, participants were provided with pieces of information as follows: 1) definition of the term \u0026ldquo;Never Events\u0026rdquo; as \u0026ldquo;events in the context of emergency care that should never occur, i.e., adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable; 2) a brief description of how the baseline Never Event catalogue had been developed 3) methodology and schedule of the Delphi procedure; and 4) specific features of the first round.\u003c/p\u003e\n\u003cp\u003eThe experts were asked to rank the relevance of each event on a 5-point Likert scale from 1 (\u0026ldquo;strongly disagree\u0026rdquo;) to 5 (\u0026ldquo;strongly agree\u0026rdquo;). Completing the vote for every statement was mandatory. All the experts were explicitly asked to give their comments on each statement and the information issued with it. For this purpose, free text boxes were provided at the end of each statement. After finishing rounds 1 and 2, respectively, each expert had the opportunity to propose additional statements.\u003c/p\u003e\n\u003cp\u003eThe participants were asked to respond within two weeks and were sent a reminder email one week and two days before the deadline day. The interim results of the voting process were presented to participants at the beginning of rounds 2 and 3, including the mean scores for each statement. Statements on the threshold to the predetermined acceptance criteria were highlighted via the original statement, expert comments, and the proposed modification of the statement. All the comments were anonymized. This was intended to encourage reflection at the beginning of each round of votes. The survey was repeated three times until consensus according to the predefined criteria had been reached or an item had been rejected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis and definition of consensus: Rounds 1 to 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe calculated the mean ranking for each statement. For the first and second rounds, we used a consensus threshold of 75%, i.e., statements with a mean of 3.75 or greater were defined as \u0026ldquo;consented\u0026rdquo;. The remaining statements were either discarded or modified based on expert comments. For the final round, the consensus threshold was 50%, i.e., statements with a mean of 2.5 or greater were defined as \u0026ldquo;consented\u0026rdquo;. Statements with a mean of less than 2.5 were discarded.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEighty-three experts participated in round 1, and 68 experts completed rounds 2 and 3 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For demographic data of the Delphi panel see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic data of the Delphi panel\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (n)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.8 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95.2 (79)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26–35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.4 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36–45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.7 (28)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46–55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.8 (38)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56–65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.7 (13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt; 65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.4 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional background\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmergency Physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.1 (69)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParamedic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.5 (12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.4 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional Experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5–10 years\u003c/p\u003e\u003cp\u003e\u0026gt; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.4 (7)\u003c/p\u003e\u003cp\u003e91.6 (76)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdditional Qualifications\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEMS Medical Director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.0 (44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResearch Activities in Emergency Medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.5 (37)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEMS teacher/ instructor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.5 (22)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMass Casualty Expert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.1 (15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMembership in Professional Organisations\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(Multiple answers permitted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en = 158\u003c/p\u003e\u003cp\u003e(1.9 per capita)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e27 initial statements addressing Never Events were proposed after literature review and adaption to the criteria developed by the National Quality Forum in the United States in 2011. In rounds 1 to 3, a total of 24 items exhibited an approval rate of 75% or more, with eight items of more than 50%; only one item was not approved as a Never event during the consensus process (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Another six statements were proposed by the experts during rounds 1 and 2.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRanking of the NEVER Items Rounds 1 to 3\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRound 1\u003c/p\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(n = 80)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRound 2\u003c/p\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(n = 68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRound 3\u003c/p\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(n = 68)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo. of expert\u003c/p\u003e\u003cp\u003ecomments\u003c/p\u003e\u003cp\u003etotal/per round\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo. of\u003c/p\u003e\u003cp\u003emodifications *\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eRelevant\u003c/p\u003e\u003cp\u003eRating\u003c/p\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eAccepted as\u003c/p\u003e\u003cp\u003eNever Event\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApproval rate \u0026gt; 75% (rating \u0026gt; 3,75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with an airway management error\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,89\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmission of telephone assisted CPR instructions despite identification of cardiac arrest and availability of trained personnel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,59\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with a medication error\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,55\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransport to medical facility unqualified for required treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10/10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,51\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath or serious disability of an infant associated with inadequate therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,46\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with inadequate education and training ⌂\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,38\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with inadequate handling of medical products (respirator, defibrillator etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,28\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInadequate postmortem examination (declaration of death despite presence of vital signs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15/15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,26\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with unavailability of an emergency unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30/15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with undertreatment ⌂\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,23\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with overtreatment ⌂\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8/8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,21\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with failure to render assistance on part of EMS personnel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10/10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,19\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with hypoglycaemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,13\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere violation of privacy or professional secrecy (e.g., handing out EMS photographs or videos to the media)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with the use of restraints while being cared for by EMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with refusal of transport by a patient lacking capacity of consent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with inadequate patient data management ⌂\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3/3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e4,00\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with inadequate immobilisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20/10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,99\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient or employee death or serious disability associated with transport using red light and siren\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,99\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient or employee death or serious disability associated with massive violation of Work Hours Act ⌂\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,87\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with inadequate fixation of EMS equipment during transport\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,86\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployee death or serious disability associated with lack or inadequate use of protective gear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,86\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSexual assault on a patient at any time during an EMS mission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32/10,67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,82\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with failure to alert special units (helicopter, divers, rescue from heights)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,81\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eApproval rate \u0026gt; 50% (relevant rating \u0026gt; 2.5 and \u0026lt; 3.75)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny instance of care ordered by or provided by someone impersonating a physician or EMT/paramedic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25/8,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,67\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath or serious disability of a patient, employee or third party associated with inadequately managed critical incidents ⌂\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17/8,5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,63\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with a burn incurred from any source while being cared for by EMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2,85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30/10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,57\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with minor injuries according to triage in a mass casualty incident\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33/11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,54\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with invasive procedures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,53\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrehospital or immediately post-handover death in an NACA I-III class patient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43/14,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,15\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePressure ulcers immediately acquired during an EMS mission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e3,07\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath or significant injury of a patient or staff member resulting from a physical assault at any time during an EMS mission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2,88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33/11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e2,88\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNot approved (relevant rating \u0026lt; 2.5)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient death or serious disability associated with patient elopement (disappearance) during an EMS mission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2,57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2,24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31/10,33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e2,24\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003eno\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e⌂\u003c/b\u003e Additional items suggested by experts during rounds 1 and 2 * based on expert feedback from rounds 1 and 2\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eIn this study, we introduce a Delphi approach for achieving basic consensus on patient safety in EMS. The Delphi method is widely used in health research to establish best practices via joint expertise in fields where evidence is limited or inconsistent [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the process quality of Delphi studies is frequently unclear because of a lack of standardised reporting. Nasa et al. recently proposed nine systematic quality tools for evaluating the Delphi methodology, including identification of the problem area of research, selection of the expert panel, anonymity of panellists, controlled feedback, iterative Delphi rounds, consensus criteria, analysis of consensus, closing criteria, and stability of the results [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the conception and presentation of this study, we aimed to take these tools into account. As a result of our survey, 32 out of 33 items were regarded by EMS experts to be serious, largely preventable, adverse and reportable and thus fulfilled the US National Quality Forum’s (NFQ) criteria for Never Events [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The items receiving the highest levels of consent were “Patient death or serious disability associated with an airway management error” (4.89 rating), “Omission of telephone-assisted CPR instructions despite identification of cardiac arrest and availability of trained personnel” (4.59) and “Patient death or serious disability associated with a medication error” (4.55). At the time of our survey, however, those three incidents were anything but rare. Airway management errors were a serious issue in 2014 and continue to be a threat to patient safety. In 2007, a New York study group reported an 8.3% rate of unrecognised esophageal intubation and a 20% rate of right mainstem intubation. Only one patient survived to discharge [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the same year, Timmermann et al. reported undetected esophageal intubation in 10 out of 150 patients (6.7%), seven of whom died within the first 24 hours after beginning treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These findings occurred despite clear evidence that the use of continuous end-tidal carbon dioxide monitoring can effectively reduce the rate of unrecognised misplaced intubations in the EMS to zero [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. After bundles of safety measures for prehospital airway management have been implemented in many EMS systems, the rates of catastrophic errors seem to decrease. This assumption is supported by a recent study from a German helicopter-based EMS showing a 1.2% rate of unrecognised esophageal intubation, i.e., an 80% decrease compared with that reported in the study by Timmermann et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Nevertheless, those errors pose a persistent threat to patient safety in EMS.\u003c/p\u003e\u003cp\u003eTackling the problem of nonprovision of dispatcher assisted CPR (DA-CPR) instructions seems even more challenging, as DA-CPR rates in central Europe were as low as 22.5% at the time of our first Delphi study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This is true although CPR guidelines worldwide have advocated the use of DA-CPR since 2010 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. According to the EURECA TWO study from the year 2020, the median rate of DA-CPR was still only 37.3%, ranging from 3.2–87.8% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSevere harm resulting from a medication error may be difficult to identify. Nevertheless, a small number of studies have addressed that issue by the year 2014, and Delphi experts have classified patient death or serious disability resulting from those events as fully preventable [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Eight years after our study, a 2022 study from Doha reported a 4.3% rate of adverse events among 3475 EMS patient records. These findings imply that re-evaluating medication errors as largely preventable may be necessary [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe fact that the experts consented almost all items proposed as Never Events, although some are quite common in everyday practice, is a dilemma and may have various reasons: The fact that events occur regularly that experts consider as potentially dangerous and preventable might indeed represent a serious challenge that prehospital emergency care is facing. However, the problem could be due to the methodology of this study, i.e., experts may not have been informed precisely enough when to define an item as a Never Event, or the threshold for consensus may have been too low.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn Delphi consensus, wording is a critical issue. Thus, only experts from the German speaking countries Germany, Austria and Switzerland were invited, so that transferring the results to EMS systems worldwide may be difficult. Also, with an extensive list of 32 events deemed preventable by all means, reaching our study goal seems doubtful. In addition, the study was performed in the year 2014. Hence, further research is necessary prior to the publication of a practically applicable catalogue of Never Events.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe topics of patient and employee safety in the prehospital emergency environment have received some attention in the past, but until today, there is a lack of robust evidence and best practice recommendations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The Never Event approach may prove valuable with respect to establishing a safety culture in EMS. Because criteria for Never Events have been redefined over the past decade, a follow-op Delphi process entitled NEEMS-2-Study was undertaken in November and December 2024 to generate a more concise and practical list of Never Events for prehospital emergency care settings. The results of this study will be published promptly.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eCompeting interests: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003ePrior Presentations: None\u003c/p\u003e\n\u003cp\u003eFunding Sources/Disclosures: None\u003c/p\u003e\n\u003cp\u003eHuman Ethics declaration: Ethical review and approval were waived for this study after the concept was presented to the ethical committee of the medical faculty of Lubeck University.\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials: \u003c/p\u003e\n\u003cp\u003eConsent to Participate declaration: Informed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003eConsent for Publication declaration: Not applicable.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available upon request from the corresponding author.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Quality Forum (NQF). Serious Reportable Events in Healthcare \u0026ndash; 2011 Update: A Consensus Report. Washington D.C. 2011\u003c/li\u003e\n\u003cli\u003ehttps://www.england.nhs.uk/patient-safety/revised-never-events-policy-and-framework/ (last accessed on June 18, 2025)\u003c/li\u003e\n\u003cli\u003eMarung H, Moecke Hp, Poloczek S, Lenz M. Never Events: Building a consensus on Patient Safety in Prehospital Emergency Care. Resuscitation 2015; 86: S122-123 DOI: 10.1016/j.resuscitation.2015.09.290\u003c/li\u003e\n\u003cli\u003eTimmermann A, Russo SG, Eich C et al. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg 2007; 104: 619\u0026ndash;623 DOI: 10.1213/01.ane.0000253523.80050.e9\u003c/li\u003e\n\u003cli\u003eMisasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019; 10:2042098618821916. DOI: 10.1177/2042098618821916\u003c/li\u003e\n\u003cli\u003eWnent J, Seewald S, Heringlake M et al. Choice of hospital after out-of-hospital cardiac arrest - a decision with far-reaching consequences: a study in a large German city. Crit Care 2012;16: R164. DOI: 10.1186/cc11516\u003c/li\u003e\n\u003cli\u003eBiewener A, Aschenbrenner U, Rammelt S et al. Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma. 2004;56: 94-8. DOI: 10.1097/01.TA.0000061883.92194.50\u003c/li\u003e\n\u003cli\u003eFink A, Kosecoff J, Chassin M, Brook RH. Consensus methods characteristics and guidelines for use. Am J Public Health 1984; 74:979e983. DOI: 10.2105/AJPH.74.9.979\u003c/li\u003e\n\u003cli\u003eBoulkedid R, Abdoul H, Loustau M et al. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS One. 2011;6(6):e20476. DOI: 10.1371/journal.pone.0020476.\u003c/li\u003e\n\u003cli\u003eGraham B, Regehr G, Wright JG. Delphi as a method to establish consensus for diagnostic criteria. J Clin Epidemiol 2003; 56:1150e1156. DOI: 10.1016/s0895-4356(03)00211-7\u003c/li\u003e\n\u003cli\u003eNasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol. 2021; 11:116-129. DOI: 10.5662/wjm.v11.i4.116.\u003c/li\u003e\n\u003cli\u003eWirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care. 2007; 11:213-8. DOI: 10.1080/10903120701205935.\u003c/li\u003e\n\u003cli\u003eSilvestri S, Ralls GA, Krauss B et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;45:497-503. DOI: 10.1016/j.annemergmed.2004.09.014\u003c/li\u003e\n\u003cli\u003eLorenzen U, Marung H, Eimer C et al. Quality and Safety in Prehospital Airway Management \u0026ndash; Retrospective Analysis of 18.000 Cases from an Air Rescue Database in Germany. BMC Emerg Med 2024 DOI: 10.1186/s12873-024-01075-x\u003c/li\u003e\n\u003cli\u003eStipulante S, Tubes R, El Fassi M et al. Implementation of the ALERT algorithm, a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol, in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres. Resuscitation. 2014 Feb;85(2):177-81. DOI: 10.1016/j.resuscitation.2013.10.005.\u003c/li\u003e\n\u003cli\u003eKoster RW, Baubin MA, Bossaert LL et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation. 2010;81(10):1277-92. DOI: 10.1016/j.resuscitation.2010.08.009\u003c/li\u003e\n\u003cli\u003eGr\u0026auml;sner JT, Wnent J, Herlitz J et al. Survival after out-of-hospital cardiac arrest in Europe-Results of the EuReCa TWO study. Resuscitation 2020, \u003cem\u003e148\u003c/em\u003e, 218-226. DOI: 10.1016/j.resuscitation.2019.12.042 \u003c/li\u003e\n\u003cli\u003eKupas DF, Shayhorn MA, Green P, Payton TF. Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors. Prehosp Emerg Care. 2012 Jan-Mar;16(1):67-75. DOI: 10.3109/10903127.2011.621046.\u003c/li\u003e\n\u003cli\u003eFairbanks RJ, Crittenden CN, O\u0026apos;Gara KG, et al. Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. Acad Emerg Med. 2008 Jul;15(7):633-40. DOI: 10.1111/j.1553-2712.2008.00147.x.\u003c/li\u003e\n\u003cli\u003eHoward I, Howland I, Castle N et al. Retrospective identification of medication related adverse events in the emergency medical services through the analysis of a patient safety register. Sci Rep. 2022; 12:2622. DOI: 10.1038/s41598-022-06290-9.\u003c/li\u003e\n\u003cli\u003eO\u0026acute; Connor P, O`Malley R, Oglesby AM et al. Measurement and monitoring patient safety in prehospital care: a systematic review. Int J Qual Health Care. 2021;33:mzab013. DOI: 10.1093/intqhc/mzab013.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6908453/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6908453/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePrehospital emergency care is often conducted under challenging and unpredictable conditions, creating a high-risk environment for both patients and healthcare professionals. Despite its significance, the topic of safety has historically received limited attention in rescue sciences. Our study aimed to develop a consensus-based set of safety indicators for Emergency Medical Services (EMS). To achieve this, we adapted the \"Never Event\" concept - widely established in clinical settings in the United States and the United Kingdom over the past decade - to the context of prehospital emergency care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA three-round web-based Delphi process was conducted in 2014 among experts in the field of emergency care to achieve consensus on Never Events specific to the prehospital environment. Primary outcome was the mean rating of item relevance on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Statements were considered consensual if they achieved a mean rating of \u0026ge;\u0026thinsp;3.75 in rounds 1 and 2, and \u0026ge;\u0026thinsp;2.5 in round 3.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 83 experts participated in round 1, with 68 completing rounds 2 and 3. The highest levels of agreement were reached for the following statements: \u0026ldquo;Patient death or serious disability associated with an airway management error\u0026rdquo;, \u0026ldquo;Omission of telephone-assisted CPR instructions despite identification of cardiac arrest and availability of trained personnel\u0026rdquo;, and \u0026ldquo;Patient death or serious disability associated with a medication error\u0026rdquo;. Overall, 32 events were regarded by the expert panel as \u0026ldquo;preventable by all means\u0026rdquo;.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eGiven the extensive list of 32 events, reaching the aforementioned study goal appeared to be doubtful. Further research is mandatory to establish broad expert consensus on Never Events in EMS.\u003c/p\u003e","manuscriptTitle":"Delphi Consensus on Never Events in Emergency Medical Services – NEEMS-1-Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 12:47:45","doi":"10.21203/rs.3.rs-6908453/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e00a38d-3243-4f95-b52c-6ec629efac50","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T07:08:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-18 12:47:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6908453","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6908453","identity":"rs-6908453","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}