How can EMS leaders, already weighed down with projects and deadlines, find time to work on safety culture?  Or maybe the question is, “How can they NOT find the time?”  Good leaders understand how defining the vision, helping their crews support it, creating urgency, and removing barriers will move their team to a safer experience.



Leaders at the EMS agency scratched their heads in puzzlement and frustration.  The investigation of a serious clinical error identified significant process failures that led to a patient's death.  They also found patterns of behavior by front-line crews that contributed to the error.  They hired good people, trained them well, utilized the best equipment, and implemented progressive protocols.  So how could this happen?

Further investigation revealed that middle managers had allowed crews to take shortcuts and workarounds, bypassing established protocols.  The managers hoped to keep everyone “happy.” As long as things got done, no harm no foul--right? The shortcuts meant some performance metrics were improving, reflecting well on the managers. But as time passed, the shortcuts were normalized and became hardwired into agency practices. Acceptance of workarounds became part of its culture, ultimately leading to unsafe practices that caused the patient's death.

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Patient harm in healthcare—including EMS-- happens every day.  Clinical errors can have many causes, and no event is the same.  Leaders need to encourage clinicians to recognize and report errors; crews can’t be afraid to report a mistake for fear of punitive actions.  This culture shift requires leaders who are actively engaged in promoting safe care, not just relying on staff to do the right things.   While unfortunate, errors shouldn’t be a surprise. A strong safety culture promotes efforts to find, investigate and learn from the unfortunate events that happen.

EMS has made significant strides in provider safety. However, many leaders haven’t made similar progress with patient safety in the clinical setting.  The reasons for this difference include lack of awareness of clinical risks; assuming somebody else (the medical director?) should ensure patient safety; or assuming the crews alone can support patient safety.   The culture pivot to patient safety requires specific leadership action within an organization, including steps to address the silos that separate clinical and workforce safety; one is not more important than the other. The key components of a strong safety culture can address both.


Dr. Froelke is an Assistant Professor of Emergency Medicine at Washington University School of Medicine. He is board certified in Emergency Medicine and holds a subspecialty certification in EMS.  He is the Medical Director for EMS as well as the Community Health Access Program at Christian Hospital.  He has served as the regional EMS Medical Director for the East Central Region since 2007 and served as the State EMS Medical Director for Missouri from 2013-1016.  He is the President of the Interstate Disaster Medical Collaborative.  Dr. Froelke has been the EMS Medical Advisor to the Center for Patient Safety since 2017.


Dr. Brian Froelke Washington University School of Medicine

Brian LaCroix is recently retired as President and EMS Chief of Allina Health Emergency Medical Services, St. Paul, Minnesota. He has worked as a volunteer firefighter, emergency medical technician, paramedic, educator, author, peer counselor, manager and executive officer. LaCroix is a Fellow in the American College of Paramedic Executives, holds a paramedic degree, a bachelor’s degree in business and has completed post-graduate studies in business administration. He is the current president of the National EMS Management Association and serves as the liaison to the Paramedic Chiefs of Canada. 


Brian LaCroix NEMSMA

Measure Your Culture Today!

The EMS Safety Culture Survey Assessment should be an organization’s first step to safety. Without an accurate understanding of where you are, and measurable data, your starting point is unknown. Use reliable data and then apply proven methods of improvement. We’ve also developed the ONLY culture surveys that align with AHRQ surveys for emergency medical services and home care.

“The culture of an organization will either deter or drive the organization’s ability to accomplish its mission.  In EMS we discuss safety in our leadership huddles, attend safety seminars and safety presentations at conferences, but the most profound insight into our culture of safety can be achieved through introspection.  At Cox Health EMS, our use of the EMS patient safety culture survey has been crucial in understanding how our staff view safety and our efforts to improve it.  The information learned has been invaluable to our ability to enhance the safety of our organization for staff and patients.”

Mark Alexander CoxHealth EMS