Decrease in medical command errors with use of a "standing orders" protocol system

The purpose of this study was to determine the physician medical command error rates and paramedic error rates after implementation of a "standing orders" protocol system for medical command. These patientcare error rates were compared with the previously reported rates for a "required call-in" medical command system (Ann Emerg Med 1992; 21(4):347-350). A secondary aim of the study was to determine if the on-scene time interval was increased by the standing orders system. Prospectively conducted audit of prehospital advanced life support (ALS) trip sheets was made at an urban ALS paramedic service with on-line physician medical command from three local hospitals. All ALS run sheets from the start time of the standing orders system (April 1, 1991) for a 1-year period ending on March 30, 1992 were reviewed as part of an ongoing quality assurance program. Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 "command" runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by χ² analysis). The on-scene time interval did not increase with the "standing orders" system. Concurrent with implementation of a standing orders protocol system, there was a decrease in the overall patient care error rate in this prehospital care system, and a slight decrease in the mean on-scene time interval. Paramedic errors occurred at a relatively low frequency with the standing orders system, demonstrating the safety of this system of medical command.