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EMS NEAR MISS REPORTING TOOL

Welcome to the EMS Near Miss Reporting Tool developed by the Center for Leadership, Innovation and Research in EMS in cooperation with the National Association of Emergency Medical Technicians (NAEMT). This tool has been created for EMS practitioners to anonymously share near-miss information by answering a series of questions in an online format. The data collected will be analyzed and possibly used in the development of EMS policies and procedures, as well as for the purpose of training, educating and preventing similar events from occurring in the future. No individual responses will be shared or transmitted to other parties.

Thank you very much for reporting your EMS Near Miss incident. The information you provide will contribute to saving lives in the future.

EMS Near Miss Event: An unplanned event that did not result in injury, illness, or damage to an EMS practitioner, vehicle, aircraft, or equipment, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage. A near miss event that is patient related should be reported as a "Patient Safety Event".

EMS Event Resulting in Illness, Injury or Damage: This tool is NOT designed to collect events involving illness, injury or damage. Those events should be reported to your EMS agency as directed by your agency policy.

EDUCATORS AND STUDENTS: If you want to practice submitting simulated events, do not use the form on this page, use our student practice form instead.

State or Province Where Near Miss Occurred*
US Only: FEMA Region (Click the link to the left for a map of the FEMA Regions)

What was your event participation?*
_________________________
DETAILS ON EMS ORGANIZATION WHERE NEAR MISS OCCURRED
Level and Type of Provider Organization:*
Department Type (Check all that apply): VolunteerPaid Combination, mostly volunteerCombination, mostly paid Governmental (for example town, city or county combination EMS/fire or EMS/police service)Third Service (governmental, neither EMS/fire or EMS/police) State/ProvincialFederal Tribal/First NationPrivate Service -Nongovernmental Nongovernmental - Non ProfitHospital IndustrialTraining Academy Other (explain below)
Describe Other Department Type:
Service Area (check all that apply): Urban Suburban Rural Remote/Frontier
How many annual responses does the Near Miss service have?*
Shift structure of Near Miss Department (check all that apply): Full-TimePart-Time Volunteer8 hour shift 10 hour shifts12 hour shift 14 hour shift24 hour shift 48 hour shiftDay shift hours shorter than night shift hours 12 hours off between typical shift16 hours off between typical shift 24 hours off between typical shift48 hours off between typical shift 72 hours off between typical shift96 hours off between typical shift No regularity between these shiftsRegularly scheduled between primary employment shifts 1 shift per standard rotation2 shifts per standard rotation 3 shifts per standard rotation4 shifts per standard rotation 5 shifts per standard rotationRotating schedule (2-2-4) or similar Rotating schedule (3-3-3) or similarRotating schedule (3-3-4-4-3-3-7) or similar Straight daysStraight evenings Straight nightsOther (describe below)
Describe Other Shift Type:
How frequently are Overtime or Extra Shifts available with the Near Miss Department?*
_________________________
DETAILS ABOUT PRACTITIONER PRIMARILY INVOLVED IN NEAR MISS EVENT
Job or Rank With Near Miss Department (check all that apply) Director or ChiefAssistant Director or Chief Safety OfficerTraining Officer Quality CoordinatorShift Supervisor Assistant Shift SupervisorALS Provider BLS ProviderFirst Responder VolunteerOther (explain below)
Other Job or Rank Detail:
Age at time of Event*
EMS Experience at time of Event (in years)*
Did the event occur following other employment or working additional shifts?*
Time off before the beginning of the shift in which the Near Miss event occurred:*
Describe other employment shifts
_________________________
NEAR MISS EVENT INFORMATION
Near Miss Event Type (check all that apply) Ground EMS EventAir Medical Event During routine inspectionDuring dispatch process During Emergent ResponseDuring Non Emergent Response During Aircraft Landing at Scene or AirportOn Scene During Emergent TransportDuring Non Emergent Transport During Aircraft Landing at Facility or AirportAt Destination Facility Going to, coming from, or at, base station or posting locationDuring Training Event During base station or posting location shift dutiesOther (describe below)
Describe other phase, location or circumstances of Near Miss event type
Year Near Miss Event Occurred*	Month Near Miss Event Occurred*

Near Miss Event Actual or Approximate Time*	Visibility at time of Near Miss Event*
How many hours into the shift were you when the Near Miss event occurred?*
Weather at time of Near Miss Event
Contributing Factors (Select up to 5) AccountabilityCommand CommunicationDecision Making EquipmentFatigue Distracted driver/pilot (radio, cell phone, other)Horseplay Human ErrorIndividual Action ProcedureProtocol Situational AwarenessSOP / SOG StaffingTask Allocation TeamworkTraining Issue UnknownWeather Violent patientViolent non-patient Other (describe below)Inadequate lighting
Describe Any Other Contributing Factors
What prevented injury, illness or damage in this event?
Unusual Circumstances. Was there anything unusual immediately preceding the Near Miss event that led to the error?
Unusual Circumstances
Do you think this will happen again in this department?*
_________________________
NEAR MISS EVENT DESCRIPTION
Describe the event. (Describe the event in the space provided. Your narrative will be reviewed for quality and content. A reviewer will remove all identifying department indicators, names or other information that may identify you or your department. In the next section, you will be asked for suggestions on preventing similar events.) Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision making, Equipment, Incident command, Role, Sleep patterns, Situational awareness, SOP / SOG, Staff, Task allocation, Teamwork, Training, Weather.
Description*
_________________________
LESSONS LEARNED
Describe the lessons learned as a result of the incident. (What lessons were learned? What are your suggestions to prevent a similar event? What actions can correct the situation? This will be reviewed for quality and content. A reviewer will remove all identifying department indicators, names or other information that may identify you or your department.) Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision making, Equipment, Incident command, Role, Sleep patterns, Situational awareness, SOP / SOG, Staff, Task allocation, Teamwork, Training, Weather.
Lessons Learned*
What system changes could be made to reduce the chance of this event reoccurring?
_________________________



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How to Report

To make an anonymous report on an EMS incident, please click one of the following links below:

Near Miss Event

Patient Safety Event

Line of Duty Death Event

Violence Event

FEMA Regions

EMS NEAR MISS REPORTING TOOL

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