I have been heartened to learn that contrary to my remembrance of paramedic school, many medics and medic students are reporting to me that yes, they are being drilled in the 6 R’s(Right Drug, Right Dose, Right Route, Right Time, Right Patient, Right Documentation) of Medication Safety. I hope that not only is this the case in school, but that it will continue out in the field – that medics will not forget what they have learned and that their field instructors will rehammer it into them. Good habits learned and reinforced early are hard to shake.

As I have written before I don’t remember learning much about this in medic school and in my twenty years in the field, I have rarely seen medic students or other medics follow any kind of consistent drug double check before pushing the plunger.

I look at the label – I try to look at it twice, but I have never gotten into a habit of calling the drug name out loud. In most cases the second look will do the trick. There have been a number of times I have seen sodium bicarb screwed into the bristojet instead of dextrose. I don’t like anyone to draw my meds up, but I have worked with a number of people over the years and some non-medic partners enjoy getting the drugs out for the medic, particularly on unresponsive diabetics. I sink the IV, attach the line and my partner is there handing me the bristojet. I don’t encourage it, but some partners are used to doing it, so I try to always read the label.

As I chronicled in earlier posts, I have given the wrong drug before, but not for many years as I have worked hard to correct bad technique. My errors included, in a cardiac arrest situation, giving epi when I thought I was giving atropine and vice versa. Giving Dimenhydrinate (Dramanine) instead of Diphenhydramine (Benadryl) to a patient with a dystonic reaction. I couldn’t figure out why the patient wasn’t coming out of it. And once I almost gave high dose epi instead of narcan as they both came in the small one cc glass vials with the orange label. One small error I have made several times over the years is giving Lactated Ringers instead of Normal Saline. You might think no biggie because they are basically the same – at least in terms of the amount I was running in — but embarrassing nonetheless. Recently I went so far as to spike and hang LR. I keep my Saline in one place and don’t in fact carry Lactated Ringers as it is no longer required. Someone perhaps thinking they were doing a good deed, put three bags of LR in my ambulance in the spot I use for NS. I reached up for the Saline, pulled down the Ringers and didn’t catch it until I had already spiked it. I cursed myself for assuming the bags I counted in the morning were Saline and tossed the bag out. I stood up and dug through the cabinet shelf for the Saline.

But the right drug error is more than just giving one drug when you think you are giving another. You might give the “right” drug to the wrong person. For instance are they allergic to it? I do ask “Do you have any allergies?” with regularity, but when many of my patients have dementia, I sometimes have to relay on the W-10. The problem is sometimes allergies say one thing on the patient’s W-10, and another on the same patient’s MAR that has the drug information. I once gave a patient ASA because I brain farted and missed the NSAIDs written in the allergy space on the MAR. I soon recognized my error and gave some benadryl as a precaution.

And then there are the contraindications. Nitro might be good for a patient with chest pain, but not if they have just taken Viagra. I have never had a patient admit taking Viagra to me. I did once have a Doctor tell me the patient in his office who was having an MI was on Viagra and should not be given NTG. Is this a question you ask before squirting NTG in a patient’s mouth? On the same drug, if your patient is having an inferior MI with right ventricle involvement, NTG would be the wrong drug.

Then of course there is out and out wrong diagnosis. For years I gave Lasix to patients with pneumonia. I didn’t do it on purpose. The patient was in severe respiratory distress and sounded like a washing machine. But differentiating between CHF and pneumonia is not always as straightforward as it may seem. It is such a common misdiagnosis that many EMS systems have removed Lasix from their formularies. While we haven’t officially removed it yet, I have stopped giving it a couple years ago. Let CPAP and NTG work their magic instead.

I always ask myself before giving a drug. “Is this drug the right drug?” “Is it necessary?” “Am I sure?” Simple, but essential questions.

And finally, it should go without saying if you do give the wrong drug, you need to report it. Report it to the ED staff, document it in your report and let your medical control know.

In my last post, I asked if a medic gives the wrong drug in the back of an ambulance and no one sees him do it, did the patient get the drug? (ala if a tree falls in the forest, does it make a sound?)

It has been my observation over the years that the number one reported wrong drug error (at least in these parts) involves controlled substances. Ativan instead of morphine or morphine instead of ativan. Why is that? Because controlled substances are tracked and other drugs are not. No one will miss the cardizem, but you have to account for the ativan.

You can debate why medics might not report their errors. They fear discipline. They fear they could loss their jobs and or the respect of their peers. Or they might think no apparent harm, no foul. Or no one saw me, it didn’t happen.

You can say not reporting an error is unethical (and I don’t disagree), but I think systems have a responsibility to create an atmosphere where people won’t fear retribution for making an error. While individuals bear responsibility for giving the right drug, the system bears responsibility for creating an atmosphere where people and the system are allowed to learn from errors and where every error is examined and action take to avoid similar errors from occurring in the future.

As an EMS coordinator, as long as medics are honest with me they have nothing to fear. Lying is what gets people in trouble.

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When I went to nursing school, I found two of the biggest differences between nursing and paramedic education were the nursing emphasis on medication safety and asepsis. While I do not recall being taught about either in paramedic school, since that was almost twenty years ago, my recollection may be poor. We no doubt touched on both subjects, but likely we touched upon them only in passing. I can say that in my two decades of field medicine, both in my own practice and in observation of my peers, medication safety and aspepsis are not often high on the priority list.

In 1999 Institute of Medicine Report issued their landmark report: Too Err is Human. They estimated that between 44,000 and 98,000 people die in hospitals each year as a result of preventable medical errors. That’s more deaths than motor-vehicle wrecks, breast cancer, and AIDS combined. They reported that serious errors occurred most often in emergency departments, operating rooms and intensive care units. The cost of these errors was estimated to be between $17 billion and $29 billion per year in additional care, lost income and household productivity, and disability.

Listen to this key statement: “The majority of medical errors do not result from individual recklessness.” Faulty systems are usually to blame. Now this doesn’t mean that people should be excused from their responsibility or not be held accountable for their errors. What is does mean is that when errors are made, we should always look at how they were made and how they could be prevented. If a person can make an error, other people can likely make the same error, so we need to look at the system and figure out how to make it harder to make that error.

A great example of this, which I wrote about in Medication Errors – Epinephrine – is stocking high dose epinephrine. If medics have to draw up high-dose epi either in a syringe to give IM or to be diluted to give IV, there exits the opportunity for a patient to get a lethal dose. Its not going to happen every time, but there have been a number of fatalities due to just this accident waiting to happen. So, to prevent lethal errors, you change the system – you provide epi-pens instead of high-dose vials. It’s more expensive, but it can spare lives.

The aviation industry has long been a leader in safety initiatives. Their Aviation Safety and Reporting System (ASRS) documents adverse events and near misses. Anytime someone even imagines how an accident could occur, it is analyzed and the system made safer.

Hospitals are required to report adverse events. Serious Reportable Events (SREs) developed by the National Quality Forum, include 28 events that must be reported, including death or serious disability from medication error.

I’ve recited to you the stats on hospital errors, but when it comes to EMS – a far more uncontrolled environment, there is virtually no error reporting. EMS treats 30 million patients a year. 10 million patients receive at least 1 medical intervention defined as a medication, IV, CPR, or advanced airway. We have many inexperienced providers.* There is minimal oversight in EMS. If a tree falls in the forest, does it make a sound? If a medic alone in the back gives the wrong medicine, did the patient receive it?

Sit around a table after work drinking beers with your coworkers and listen to the tales. It is the Wild West. Sure there are many medics – the majority, I believe — who do heroic deeds and provide professional care, but there are some other tales out there that would make shocking stories on 60 Minutes.

In the coming weeks I will be writing about Patient and Medication Safety. I will of course disguise all calls so that no person, service, or patient is identified. I will also try to make some suggestions about how to make EMS a safer place.

Stay tuned.

*You can be a medic for twenty years and still be inexperienced in what you are being faced with. I have only delivered two babies. I don’t care to ever see legs dangling out again. I have never done a surgical cricothyroidotomy. I hope I never have to cut someone’s throat because I can’t guarantee you, I will do it perfectly. We have a Melker kit. I am pretty skilled with it when I have practiced it five times in a room in a skills session. But a month later face me with a real patient who needs it now, and I am first day rookie.

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