EMS Service Incident Reporting Requirements

Bureau of EMS Policy Statement
Policy Statement #98-11
SubjectRe: EMS Service Incident Reporting Requirements

The purpose of this policy statement is to provide clarification to the requirements of Section 21.q of Part 800 which specifies incident reporting responsibilities and requirements for EMS services. Reports must be made for incidents in which a patient under the charge and care of the service was injured or harmed by actions or omissions of a service employee as well as for on duty death or injury of a service member/employee.

Notification Requirements

The chief executive officer of an EMS service is required to notify the DOH Area Office of the occurance of any incident or circumstance in which a patient, or member/employee is harmed, injured or killed in any of the circumstances listed below. Questionable situations should be referred to the area office for resolution.

Notification must be made to the Department's Area office by telephone by the close of business the day following the incident and in writing within five days.

Types of Reportable Events(1)

The following types of situations must be reported to the DOH:

  • a patient dies, is injured, killed or otherwise harmed due to actions of commission or omission by a member of the ambulance service;
  • an EMS response vehicle operated by the service is involved in a motor vehicle crash in which a patient, member of the crew or other person is killed or injured to the extent requiring hospitalization or care by a physician;
  • any member of the ambulance service, while on duty, is killed or injured to the extent requiring hospitalization or care by a physician;
  • patient care equipment fails while in use, causing patient harm;
  • it is alleged that any member of the ambulance service has responded to an incident or treated a patient while under the influence of alcohol or drugs;

The definitions of the type of events listed above are very general in nature as EMS services and crews have broad and varying operating conditions and situations. The Department's interest is in those events in which a patient, under the charge and care of the service, is injured or harmed by acts of commission or omission by a service member/employee. Examples might include failure to maintain an airway, failure to resuscitate, not honoring a properly executed DNR order, dropping a patient, etc. The situations described here are not to be considered an all inclusive list.

Additionally, to meet the requirements of Part 800.21(q)2 & 3 the DOH does require the reporting of any line of duty death or serious injury of a member or employee. This means that if a member of the service is killed or seriously injured in a sudden or unexpected circumstance (not a chronic situation) a report to the Area Office needs to be made.

The written report to the Area Office needs to describe the circumstances, outcomes and injuries or deaths of all involved. A copy of any motor vehicle accident report should be included. The Department will in each instance review the report and information submitted and determine what follow up action(s) or aditional documentation will be required by the service.

Having the incident identified and/or reviewed by the service or regional Quality Improvement process does not relieve the service from these reporting requirements.

Equipment Failures

Services are to notify the Bureau of EMS in writing, of all unexpected authorized EMS response vehicle and/or patient care equipment failures that could have resulted in harm to a patient. One example is a defibrillator failing to discharge. Any corrective actions taken by the service should be included. The intent of this section is to track trends in vehicle or equipment failures so that reports may be made to manufacturers and other appropriate agencies.

The reporting of equipment failure to the Department does not relieve the agency from any requirements of the US Food and Drug Administration's(FDA) mandatory medical device reporting. A copy of any FDA report filed will meet the intent of this requirement.


1. State EMS Code, Part 800, Section 21(q) 1 -5 and Section 21(r)

Issued by: John J. Clair, Associate Director - Operations

Authorized by: Edward G. Wronski, Director