Comment: This is a truly unfortunate event. We will never know whether the loss of the sensing electrodes caused this patient’s death or not. We can though, learn a great deal from this case and there are excellent lessons to be learned from it. Thank you for sharing it.

Our reporter suggested that improved training of the ED staff might prevent similar episodes. Our editorial board must respectfully disagree. We believe that this event represents a breakdown of the system for smooth transition of care from one team to another. Clearly there was no system for the EMS crew to communicate and be heard as to care given and therapies in place. This is a common problem in areas where there is someone lower in a command structure (medic/EMS) trying to communicate to someone higher in the structure (physician/nurse/hospital).

Aviation has dealt with this issue relative to junior pilot second in command trying to make suggestions to senior pilots in command. They have since developed the concept of crew resource management which aims to empower people lower in the command structure (in this case, the paramedic bringing the patient in) to be assertive when they think that a higher command (the emergency physician receiving the code in the ED) is missing something (in this case, not taking proper control of the situation, specifically a proper handoff). This system has been extremely effective and should be implemented in EMS.

MEPARS recommends that this scenario be reviewed by the EMS system, medical directors and ED staff as a basis to form safe procedures for handoffs of patient care. It takes practice, preplanning and support from your medical director to maintain control during the patient handoff. We recommend as an example being proactive saying in a commanding voice “nobody disconnect the monitor patches or pads since the pacer currently has capture.” In this case the person lower in the command structure has something important to say that must be heard.

Welcome to “News From MEPARS”
This is our first in a series of newsletters highlighting lessons
learned from the cases reported to MEPARS. These will be
appearing on an irregular basis as cases are reported to the
system.

In This Issue
• IV hazards, Worms in EMS
• Handoffs are high risk
• Meet the Editors

Download the current Newsletter

Provider comment: The AED should not allow the possibility of powering down by simply pushing a button that looks like and is near the shock button. There should also be a message and chance to cancel powering down before actually powering down.

Comments: We agree completely with this provider. In developing devices for use in the EMS environment it is extremely important to design and test the devices for use under actual EMS conditions. This would include provisions for adverse weather, stressed, hurried users, low light and cramped spaces. The devices should also be designed so that the errors that will inevitably be made by providers under these conditions will not cause a negative outcome. In this case there should be a pause or very clear warning that the device is going to power down, particularly if a shock has just been advised.

MEPARS recommends that EMS medical devices undergo usability testing in the EMS environment before being deployed. Although the FDA now requires new medical devices to include a usability evaluation prior to approval, these tests are not necessary carried out in the EMS environment. It is important for agencies considering purchase of new AED models ask the manufacturer to share the results of their usability tests, including a confirmation that testing was conducted in a realistic EMS environment.

While this event did not necessarily occur with a Medtronics device we did contact them for comment. The attached letter confirms the efforts they have put into their current designs and the steps they have planned to address this issue.

Figure 1. Control buttons on a common AED model

July 3, 2007

Dr. Gwinn,

Thank you for your question and concern about the possibility of a user inadvertently pressing the On/Off button rather than the shock button during an AED resuscitation attempt. This has certainly been a concern of ours as well, and has been addressed by design in the following ways:

o The On/Off and Shock buttons are separated as much as feasible
o The buttons are color coded: green for On/Off, red for Shock.
o The labeling on the buttons help to further differentiate them—the word “ON” vs. the shock/lightning bolt symbol.
o The Shock button flashes to prompt a shock, indicating that it is the proper button to press.

Each of these helps the user differentiate the two buttons, and, based on my knowledge of complaints we receive, these mitigations appear to be very effective.

However, one design implementation that probably helps prevent inadvertent power off most effectively is the press-and-hold action required to turn off the defibrillator. This feature has been implemented in the LIFEPAK CR Plus defibrillator which is designed for the lay AED user. The LIFEPAK CR Plus defibrillator On/Off button must be pressed and held for at least two seconds to turn the AED off. The AED also beeps three times as it powers off.

Again, thank you for your inquiry. We are committed to improving our product designs and appreciate feedback such as yours.

Sincerely,

Patty O’Hearn, RN, MA
Manager, Clinical Affairs
Physio-Control

Further reading:

1. Fairbanks RJ, Caplan SH, Shah MN, Marks AM, Bishop PA. Defibrillator Usability Study Among Paramedics. Proceedings of the Human Factors and Ergonomics Society 48th Annual Meeting; 2004 September 24; Santa Monica CA. Human Factors and Ergonomics Society.
2. Monsieurs KG, Vogels C, Bossaert LL, Meert P, Calle PA. A study comparing the usability of fully automatic versus semi-automatic defibrillation by untrained nursing students. Resuscitation 2005;64(1):41-7.
3. Andre AD, Jorgenson DB, Froman JA, Snyder DE, Poole JE. Automated external defibrillator use by untrained bystanders: can the public-use model work? Prehosp Emerg Care 2004;8(3):284-91.
4. Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Usability Study of Two Common Defibrillators Reveals Hazards. Annals of Emergency Medicine (in press).

Root Cause: Distraction of the crew by an excited family.
Failure to identify the agent administered

Lesions Learned: The reporter recommended constant check and recheck of labels before, after and during administration.

Editor’s Comment: Family are frequently a problem. They can be distracting, intimidating and in their good intent, detract from your care. One of the challenges that make EMS so special is the need to control the scene. This is little difference between stabilizing a car at a MVA or finding the gun at a shooting and assuring that the family doesn’t distract from the care we need to provide. Try to control the scene as best as possible. You can always ask family to step out of the room. One EMS service recommends giving the family something to do, for instance compile a family history or fill out some forms.

It is also important to remember that the crews are teams of two caring for the patient. We encourage everyone to take advantage of that fact and cross check your actions with your partner. This will help avoid medication errors. In case #6 we discussed the steps to effective communications in a team and referenced the navy site at http://wwwnt.cnet.navy.mil/crm/crm/stand_mat/seven_skills/CM.asp that reviewed the components of effective communication. Call out “giving Versed 5mg IVP” and have your partner confirm the Versed dose and route.

All drug doses were within therapeutic ranges so there were no adverse effects although the patient may have lost the amnestic effect of Midazolam.

Editors Comment: This medic was set up for this adverse event before they even hit the streets. We are all creatures of habit and unless we are really made aware of changes will ocntinue to do what we always do. Generally morphine is available in 10mg/ml vials in the service area where this event took place. This medic had recently changed jobs to a new EMS service where morphine is stocked in 5mg/ml vials. Apparently it had not been made clear that this was a different concentration. On further investigation the medic also found out later that Dopamine was also a different concentration.

Although the provider had responsibility to check the medication before giving it, there is shared responsibility for this event with the EMS system. Because the new concentration was different from the regional standard (and therefore the expectation of the medics in the area), the system created a hazard which facilitated the error. In fact, safety scientists would point out that the medic’s contribution to this error might have been expected or anticipated, and was not a result of reckless behavior on their part. An agency that follows the “just culture” philosophy might educate the medic in a non-punitive manner and then make changes to the system (such as standardizing the concentration) to avoid similar problems in the future.

Although this particular case did not cause any patient harm (besides a delay in adequate pain treatment), it should serve as an indication for potential adverse events from similar underlying causes.

It is quite reasonable that this medic picked up a vial of morphine during emergency treatment and assumed it was what it had always been, 10mg/ml. As a result of this event MEPARS strongly recomends that EMS services include attention to the concentrations of the medications in their drug box in their orientation program for new medics.

Because cases like this clearly demonstrate the dangers of a lack of standardization in the EMS industry, the MEPARS editors recommend development of standard industry-wide medication concentrations.

Providers comment: Will consider Cardiac etiology for all ABD pain and 12 lead will be obtained as soon as possible. There is little time lost in adding the 12 lead over a 3 or 4 lead. This case should elevate our index of suspicion for atypical presentations of cardiac disease.

Discussion: We have probably all missed more diagnosis in our career than we care to talk about. As this provider’s medical director stated it’s inevitable you will miss some abnormal presentations of MI. The article referenced below quotes a delayed diagnosis rate up to 38% in some groups. The elderly, women and diabetics are at particular risk for this.

While missed atypical presentation of MI is a major problem we do have technologies for dealing with this problem. 12 lead EKG monitors are becoming more available for use in the prehospital environment. These along with training in interpretation of the 12 lead will greatly help with this problem. If you have one use it frequently, one you’ll catch the occasional atypical MI presentation and also you will gain skill and comfort with their interpretation. We recommend the 12 lead monitor very highly.

Finally this provider brought of the question of whether or not the dispatch for abdominal pain affected the decision making process. Always remember that developing tunnel vision from dispatch info or even other providers on scene may influence your diagnosis and cause you to develop tunnel vision, a bad thing. (see Epi vs Benedryl posted January 25th, 2007)

Reference:
Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes. By Grossman Presented at the Society for Academic Emergency Medicine National Meeting, May 2000, and the Society for Academic Emergency Medicine New England Regional Meeting, April 2000. Volume 21, Issue 5, Pages 425-428 (September 2003)

Volume 21, Issue 5, Pages 425-428 (September 2003)

3 of 13

Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes
Presented at the Society for Academic Emergency Medicine National Meeting, May 2000, and the Society for Academic Emergency Medicine New England Regional Meeting, April 2000.

ABSTRACT

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Shamai A Grossman *, David F.M Brown †, YuChiao Chang †, Won G Chung †, Hilarie Cranmer †, Li Dan †, Jonathan Fisher †, Usha Tedrow ‡, Kent Lewandrowski ‡, Ik-Kyung Jang ‡ and John T Nagurney †
Received 11 October 2002; accepted 1 December 2002.

Abstract
Delays in seeking medical attention for patients with acute coronary syndromes (ACS) preclude early application of life-saving treatment and diminish efficacy. Previous studies suggest 3-hour delays between onset of symptoms and ED arrival in patients with typical presentations of acute myocardial infarction (AMI). A prospective observational study was conducted in an urban ED measuring lag time (LT) among adults presenting within 48 hours of onset of symptoms suggestive of ACS. Univariate and multiple regression analyses were performed on 5 predictors: age, sex, symptoms at presentation, and 2 different outcomes (AMI and ACS). Three hundred seventy-four patients were enrolled. Mean age was 63 years with 38% 70 years or older. Seventy-three percent of all patients with suspected ACS presented with chest pain, 27% with atypical symptoms. Overall mean LT was 8.7 hours (standard deviation 11). In subgroup analysis, patients aged ≥70 years were more likely to have LTs >12 hours (29% vs. 19% P = .043) and patients without chest pain had longer mean LTs (11.6 vs. 7.6 hours, P = .01). Delay in ED presentation is group specific. Advanced age and patients with atypical symptoms are predictive of longer LTs. Contrary to previously published data, patients with symptoms suspicious for ACS can delay an average of 9 hours, which might alter current thinking in the prevention and care of these patients.

Keywords: Predictors, delay, emergency, coronary, chest pain

The sending facility's physician said he ordered the Labetolol bolus followed by a drip titrated for effect. We followed our own protocols and informed the sending physician we were making these adjustments.

Comment: Sometimes what appears to be an adverse event may actually be a matter of another provider having a different plan and working with different information. Our editors were unanimous in seeing this as such a case. Apparently there is good literature in the pharmacology literature to suggest that giving an IV bolus of labetolol can actually lead to a rebound hypertensive response. Based on this, starting a drip and titrating to effect is a valid treatment option. Although the treatment of the blood pressure in this case appears to be less than aggressive.

Interfacility transfer and the interaction of the sending transport and receiving teams is an extremely difficult yet crucial factor in good quality care. These hand offs take exceptional communication to be able to transmit large quantities of data quickly and accurately. Techniques to facilitate this transfer would be an excellent topic for education programs. This could also help us get away from the idea that if it isn’t happening according to our protocol it is wrong. There may be several options available to each team in treating the same patient and we need to be aware of and respect the other valid options.

We have previously referenced the work by David Wood on difficulties with transfer of care at: http://www.bmj.com/cgi/content/full/320/7237/791?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1007348856376_11525&stored_search=&FIRSTINDEX=0&volume=320&firstpage=791

Our reporter was reminded of how fragile elderly patient’s skin can be. Coumadin certainly makes any leaking from the vessel much more dramatic. This is particularly true in the transport environment where IVs are subjected to more movement and stress. This reporter’s suggestion to be more aware of potential bleeding around the catheter and reassess the IV site more frequently is certainly well taken.

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Comment: When nothing seems to go right with a case it might be that the original assumptions that you are operating might not be correct. As in this case the airway difficulty was probably due to rigor mortis. It can be difficult to establish down time particularly as in this case where the patient was under a blanket and felt warm. In this case nothing went right because of the original assumption that the patient was a candidate for resuscitation.

Other points are that there should be other methods for oxygenation if ET intubation fails prior to going to surgical airway. Bag valve mask, PtL ,combitube or LMA airways are several examples that could have been fall backs and similar procedures should be available within the EMS system.

Education may have been a factor here with what drugs are administered by ET route but bicarb has never been given by ET. It can be given by intraosseous route. Also intraosseous infusion is rapidly becoming available across the country and is an extremely effective technique if IV access can not be established.

Follow-up Comments: BLS med assists to medics were found to be common practice although drawing up meds is against policy. There was no procedure for double check prior to administration of the medication. The meds were in similar vials with similar labeling. Momentum of Dentists assessment was a factor where the dentist’s diagnosis was not reassessed by EMS prior to starting treatment. Training issues might be in the assessment of anaphylaxis and indications for epi.

Root Cause:
1. Distraction by patient confusion as to mode of transfer.
2. Communication failure between team members
3. Communications failure between sending facility and transport team.

Lesions Learned: Better communication between crew members and RN checking the drip rates after pump is set up and before leaving sending facility. Reporter also recommended readback between Nurse and Medic as a way to prevent recurrences.

Editor’s Comment: This is our second error report involving heparin infusion. It is also interesting in that in both cases the fundamental error occurred at the sending facility and was only caught later in the transport.

Our suggestions are:
1. As before, confirm all the IV solutions starting at the IV insertion site and then work back to the patient. Record primary solutions and rates and also drips and piggy backs.
2. This reporter also made an excellent suggestion of using a call back system between the medic and nurse. As the medic changes the pump he would call out to the nurse “changing Heparin 25,000 units in 500cc’s at 20 cc/hr. The nurse would then acknowledge the drip by responding Heparin 25,000 in 500cc at 20cc/hr. By doing this both confirm that this is the dose being given.
3. Also this was also (as was the first Heparin error) a non-standard concentration of Heparin. This is a red flag to be careful.
4. Again the crew did an excellent job of catching the mistake. As the transport progressed the crew calculated total fluid administered and realized that this didn’t correlate with the prescribed dose. Again this constant checking and cross checking found another error quickly.

Initially our reporter had suggested the need for improved communication as a remedy for this error. On further conversation they had suggested very specific and excellent techniques of reading back drug doses and drip rates. The point being, that there are very specific techniques to improving communication and we should not just settle for “improving communication” by its self. We should look for specific methods and techniques. The navy has broken communication down to very specific factors as described on their web page. http://wwwnt.cnet.navy.mil/crm/crm/stand_mat/seven_skills/CM.asp. As our reported suggested these techniques apply very well to all aspects of medicine