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Welcome to the MEPARS Medical Error Prevention System
Scenario: A patient became unresponsive was brought to the trauma bay with a pacer applied via Medtronics LP12 (capture at 90mAh, monitoring in lead III), ED staff removed leads from patient but left pacer on and functioning (but in doing so changed pacing mode from "Demand" to "Non-Demand" and it was no longer possible to view waveform for continued capture without reconfiguring the monitor screen. ED staff then disconnected the pacer cable from the therapy pads placed by EMS, it took up to 20 seconds to figure out how to reconnect the therapy pads, then the pacer had to be reset to 90 mA, and there was still no clear ECG to monitor for capture. the patient lost pulses, CPR was started by ED staff, an attempt at an internal pacer wire was placed but it did not appear that this produced perfusion and CPR was continued. An ultrasound preformed by an MD confirmed that there was no spontaneous cardiac activity and efforts were stopped.
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.
Scenario: We arrived at a cardiac arrest, started CPR and hooked up the AED. AED advised for shock. EMT went to push shock button and pressed the power off button. The AED then powered down. The restart took about a minute. On power up it still advised shock and one was administered. ALS arrived and the patient was in asystole. The patient did not survive the arrest. We do not know whether the one to two minute delay in shock affected the outcome of this event.
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).
Scenario: Patent was intubated due to CHF and on a Versed drip. Patient was chewing on ET tube. Decision made to paralyze patient for transport. There were many distraught tearful family members at the bedside. In addition to paralysis with Vecuronium paralysis we inadvertently gave two 1mg doses of Morphine instead of two 1mg dose of Versed as the sedative agent. The patient did not exhibit any adverse reactions. The error was discovered at the next days drug count.
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.
Scenario: Patient had a large deep laceration to the hand. Pt in significant pain. Vitals were stable so the decision was made to give morphine. I drew up what I thought was 10mg/1ml of morphine and administered 0.5ml. Pt had good pain relief and the transport proceded without event. On arrival at the ED and wasting the other 0.5ml I discovered that the morphine was in 5mg/1ml vials and the patient had only received 2.5mg of morphine
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.
Presentation: Dispatched for a middle aged patient with pain above the navel. Pt described intense burning pain from navel to right upper quadrant (10/10). Pt denied chest pain or shortness of breath or diaphoresis. Right upper quadrant is tender on exam. Treated as abdominal pain with IV narcotic and transported with normal four lead EKG, pulse ox and vital signs. 12 lead EKG in ED showed elevated ST segments in multiple leads.
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.
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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
Scenario: The patient had a stroke and was hypertensive. The sending facility had started a Labetolol IV drip @10mg/hr and had increased it to 20mg/hr. There was no IV push dose documented. The patient's BP had not decreased and was 237/138 on our arrival. Our crew gave a 20mg. Labetolol bolus and adjusted the drip to 2mg/min per our protocol. On arrival to the receiving facility the patient's BP had come down to 228/117 (this was over 6 minutes after the bolus and drip adjustment).
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
One IV was in place. While attempting a 2nd IV on a cardiac pt., I had a good flash, but I could not advance the catheter. Attempting to flush the IV w/ NSS it appeared to be patent and the catheter advanced. After 20cc's of NSS there was no infiltration, swelling, ecchymosis noted to the IV site area. Due to the pt. being cold, I had pulled the pt's sleeve down covering the IV site area. While reassessing the pt. I then had noticed that there now is a moderate size contusion approx. 6 inches long and 3 inches wide, on the top of the forearm. Pt is on Coumadin and has very thin skin. Pt. stated that this happens often now since they started me on the blood thinner. Pt did not experience any pain and stated that it is o.k., it will go away like the rest of the injuries they sustain.
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.
Scenario: We were called to residence on an unresponsive patient Pt is sitting in chair and is pale and warm to the touch. No pulse found. Family member says patient has been sleeping for an hour before he tried to wake the patient. We move her to floor and start CPR. Monitor shows asystole. ACLS is started. We were unable to open pt's airway, the neck would not bend and teeth were clenched. Needle cric plan was put into place with success. IV established on 4th attempt, it is very positional, with Epi and Atropine given through it. Line on the trans tracheal jet blew apart, after several attempts to fix it needle cric replaced with surgical cric. We at this time find out that family member had left several hours earlier. He returned and he assumed the patient was sleeping. He said after an hour he tried to wake her and she wouldn't wake. Unsure now how long pt has been down. CPR still in progress. IV blew. We try to give an amp of Sodium Bicarb down the tube, we only get half an amp in when it comes back up through the tube. Monitor still shows asystole. The patient was transported to the hospital where they were pronounced dead.
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.
Scenario: Young healthy patient at dentist’s office given Lido with epi injection, felt pounding heart and very anxious. Dentist thought anaphylaxis EMS called- Dentist told them anaphylaxis. Patient seemed to worsen Paramedic asked BLS partner to get benadryl and epi out of drug box Paramedic recalls medic asks for benadryl (partner recalls medic asked for epi)1 ml drawn up by BLS tech & given IV push by ALS tech. Patient has sustained VT, severe chest pain, diaphoresis, “feels like I’m dying.” Patient sustained MI due to inadvertent IV injection of epinephrine.
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.
Scenario: Picked up patient with a Heparin drip reported to be running at 20 cc/hr (1000 u/hr). On our arrival the medic transferred the drip from their minimed pump to ours at the same rate that was actually 50cc/hr (2500 u/hr). This was the only drip running. The patient was also surprised by the mode of transportation that had been ordered and required reassurance. The error was not identified by the nurse until enroute to the receiving facility. The receiving RN was notified and clotting parameters were obtained. While there was potential for injury the patient sustained no adverse effects as a result of this error.
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
I was setting the IV pump for pt on dopamine. I set the rate at 30ugm/kg/min instead of the current rate of 30cc/hr. The second medic caught the mistake.
Apparently the drip had been set at 30 ml/hr titrated to effect. The pump program allowed ugm and ml, per minute and hour. The provider became confused while navigating the program and trying to get to ugm/kg/min. The provider states that they developed tunnel vision, lost sight of the larger picture, and didn't realize that they were going to a higher rate.
Vasoactive drips are definitely a high risk and complex procedure, rich with potential for adverse events. All of the MEPARS editors agree that this is an area where infusion pump technology can make a huge improvement. Systems that include libraries of acceptable doses and limits give strong prompts for correct dosing. Unfortunately, these devices are not commonly available to EMS, although some are available in critical care transport. It has been said before, that as long as people are doing procedures, there will be errors in what they do. This is true even with double and triple checks. Using the built in safety features of the automated pumps reduces the likelihood of developing tunnel vision and overlooking incorrect doses.
Also, many safety experts recommend using standard dosing units, such as ml instead of cc’s. Standardizing dosing to one format cc/hr. ugm/kg/min would also be helpful.
Scenario: We responded to a report of a patient with chest pain. Prior to our arrival the patient had self-administered nitroglycerine and was pain free. The patient requested transfer to a distant hospital and we concurred since the patient was stable. Enroute the patient began to complain of dizziness. Monitor showed wide complex tachycardia. We treated the 200 lb. patient with a 200 mg lidocaine bolus, not converting the weight to kilograms. Patient did develop ringing in the ears but the rhythm did convert to sinus after several minutes. The transfer was diverted to the closest hospital and the patient experienced no further adverse effects.
Root Cause:
1. Single medic system, no opportunity to cross check dosage.
2. Failure to calculate correct medication dosage
Lesion Learned:
• Always double check my medication doses.
• Don’t be in such a hurry, calm down.
Editor’s Comment:
Fortunately this was a relatively minor incident since the dose was only 25% high and the half-life of lidocaine is so short. It does highlight the perils of calculating drug doses in your head in a noisy ambulance under sometimes adverse conditions.
The primary advantage of a two medic crew is the ability to talk and confirm treatments with each other. We have written several times about the give and take of ordering a medication and then confirming it with a partner as the dose is given. In this case a medic might says giving Lidocaine at 1.5 mg/kg or 160 mg. The partner might respond with a warning that the dose seems high for this patient. This feedback gives an additional confirmation of the correct dose. In a pinch when working by yourself it may pay to have that same conversation with yourself as you give the drug.
Another thing that can help is to think consistently in either pounds or kilogram. So instead of complaining that we had a 400 pound patient start thinking in terms of a 200 kg patient. (Dividing pounds by 2 to get kilograms is an adequate conversion for EMS purposes). Another very helpful aide is the automatic dose calculators on the IV pumps and available on many PDA programs.
So remember to communicate with your partner even if it’s yourself.
We learned during transport that we had patient's right arm and elbow wedged between the cart rail and wall. Patient was unconscious and couldn't tell us this had occurred. We learned of this 5 minutes into transport and extricated his elbow. Pt sustained a bruise to the elbow. We believe this occurred because the shoulders had been secured but not the hands.
Controlling the patient’s upper extremities has always been a difficult task particularly in an unresponsive or paralyzed patient. The major pitfall we see is the lack of a design mechanism of the stretcher to adequately restrain the upper extremities. The vehicle it’s self may have been a factor in it’s modification for EMS use. Yet another factor is a lack of standard operating procedure calling for a checklist of patient compartment security prior to transport. A written checklist works much better than trying to remember all of the things to check by oneself. This might include checks for security of straps, patency of all IV lines and monitors, positioning of the patient in the vehicle and securing all movable equipment. The result of such a checklist would be a much safer vehicle for the patient and crew.
For an absolutely riveting discussion and video regarding loose objects in the patient compartment go to http://www.objectivesafety.net/ for a presentation by Dr Nadine Levick on ambulance crash testing.
We had a patient with respiratory distress. We waited in triage line for 40 minutes. We notified the triage nurse of the fact that the patient was in respiratory distress. Pt had RR 40-50 and was getting tired. We were ignored by the nurse, who triaged three patients ahead of us
This is apparently a fairly frequent event for this crew. Usually they go to the charge nurse to get more rapid attention. This time they didn't get results from the charge nurse so they approached an ED doc in the hallway and got the patient triaged.
Comment:
Nice job of advocating for your patient! Even if it means flagging down a doc in the hallway EMS providers must take a role in advocating for their patients to obtain good care. This crew did just that. A company policy on actions to take and who to contact if this happens in the future would give those crew a much better leg to stand on when it happens again.
A more pressing issue here is the increasing waits in emergency departments across the country. The Center for Medicaid and Medicare Services (CMS) issued a position paper on this topic July 13th, 2006. They contend that parking a patient on a gurney in the waiting room is likely a violation of the EMTALA statutes and constitutes a denial of service.
This crew did well to get care for their patient. We will probably see this type of event more and more in the future. It is worth planning for so your crew will have an action plan and by working with the hospitals may help them avoid an EMTALA violation.
Scenario: We were enroute to hospital A for a transfer back to hospital B. 15 inutes out we were informed that there was a “problem”. Apparently the sending physician at hospital A had not informed the receiving physician at hospital B that the patient was in the ICU. Hospital A requested we cancel and we were told to proceed and help out while the details were worked out. We went to the ICU at hospital A and were told to wait in the ICU waiting room while the physician tried to find an accepting hospital. The crew was unable to start their care until the patient was accepted due to possible HIPPA violations. After an hour the patient was accepted to the ICU at hospital C.
Root Cause: Failure to secure a bed for the patient at the accepting facility
Overzealous attempt to accept the transport
Poor communication between hospital A and dispatcher about
availability of an ICU bed.
Lesions Learned: The transport should have been canceled as requested by hospital A. Dispatch may have misinterpreted policy with regards to the decision to “help out”.
Editor’s Comment:
There is considerable discussion as to whether or not this case represents an error or not. One might consider this an error based on time the crew was out of service waiting for the bed clearance. On the other hand this is not an error based on the fact that the crew was immediately in place for the transport when bed clearance became available. The distinction between the two perceptions is primarily economic i.e. what is the cost of the crew time versus completing the transport in a timely fashion. It is in fact company policy to continue the transport while bed clearance is being sought as requested by the attending physician. So it is possible no error was made based on policy with respect to proceeding to the referring hospital. Whether this was the best use of available resources is a matter of opinion.
This case does demonstrate one common type of error though. That is that the desire to do good, complete the mission and save the life can be overwhelming. This desire has caused many EMS professionals to launch into marginal conditions and decisions sometimes with disastrous consequences. This is the rational for our rigid limits with regard to weather minimums for air and ground transports. This has been extensively studied as the aviation concept of get homeitis where the pilot proceeds into hazardous conditions due to being too anxious to get home. Or as this analogy goes dispatch may have thought they were on the verge of getting clearance and just kept the transport going since they didn’t want to loose the request.m
Scenario:
We arrived to find a patient who had suffered Ventricular fibrillation and been revived with an out of hospital AED. The patient was given a 100mg bolus of Lidocaine and a lidocaine drip started. The intent was to start lidocaine at 2mg/hr or 15 drops/minute. The drip was started by an orienting medic at 15mg/hr or 225drops/min. The error persisted through the ED until critical care transport arrived to transport the patient. On their evaluation the high drip rate was noted. The patient suffered no ill effects and was transferred to the cardiology service
Root Cause:
• Overriding the safety features of the medication pump.
• Loss of situational control between in charge and orienting medics.
• Single medic running post cardiac arrest management and orienting a new medic.
Lesions Learned:
I should have checked the orienting medic’s calculations.
Editor’s Comment:
The most important issue in this case is the overriding of the safety features of the medication pump. As Lidocaine was chosen from the drug menu the pump presented a recommended dosage. This will probably be fairly close to the appropriate rate for most patients. If you have to deviate from this amount by a significant amount there is probably something wrong. Do not ignore this impression, it is time to rethink your plan.
Another factor is the workload involved with caring for the patient and orienting a new medic. This is a system problem and may reflect the need to add additional staff during orientation periods specifically for training.
Finally we have discussed in several previous reports the necessity for recalculating drug doses and drip rates as care of the patient transfers from one service to another. While these changes in care are risky from a patient safety standpoint in terms of communication gaps they also afford everyone a chance to stand back and re evaluate the care to that point. Here is a clear demonstration of the benefit of recalculating drip rates and drug doses as care changes hands.
Mixed Drips
Scenario: We arrived to find a patient on a ventilator with Diprovan 1000ug/ 100cc running at 5cc/hr and KCl 20meq/l running at 50 cc/hr. Both infusions were transferred to the pump for transport. During transport the Dirpovan was found to be running at 50cc/hr and the KCl solution at 5cc/hr. The drips were immediately changed. The patient showed no adverse change in vital signs.
Root Cause: Error in identifying the infusions running.
Drips were transferred to pumps prior to confirming the concentrations of the drips.
Multiple IV lines leading to confusion as to their identity
Lesions Learned: The reporter recommended the use of the four rights (Right drug, right dose, right patient and right time) applied every time a drug or drip is administered as a method to prevent further occurrences. They also recommended use of the DRC (DRC function of the pump). This is a drug dose calculator built in to the pump itself. This would be particularly useful for drugs that are unusual and hence the crews are not familiar with them. Having the dose and drip rate calculated at your fingertips would be very helpful.
Editors Comment: This is the sixth error reported with IV drip rates. This is clearly the most common source of error to date. It is certainly difficult to untangle the jungle of IV line and find out what the patient is actually getting. We have talked about changing the SOP to include total recalculation of the drip and verification of the concentrations of the drugs in the bags prior to transferring the drip to our pumps. This process of reconstructing the drip from the bag to the needle would confirm the drip and also assure that the correct lines are connected to the appropriate pumps.
Again it is impressive how fast the error was found. The constant scan, awareness and rechecking of what drip is running at what rate led to the rapid discovery of this error.
Fortunately the patient only received a slightly higher dose of Diprovan than prescribed. Since the patient was on a ventilator with constant BP monitoring the risk of this was minimal and in fact the patient suffered no adverse effects.
Inadvertent tPA bolus
Scenario: Patient was a post arrest, posterior MI patient receiving tPA. As we were changing to our pump tubing the tPA line was mistaken for the .9% NS line. As a result the last 35mg of tPA was infused in several minutes instead of one hour. I thought I had correctly traced the tPA line however due to the twist, turns and trying to work around the other people in front of the IV site the error was made. Also the tPA was a direct line with the NS run as a piggy back into the tPA. I had an ED nurse helping hold the lines during the change over. The patient had a negative CT scan at the receiving facility.
Root Cause:
Confusion at a time of change.
Unfamiliarity with or non standard IV practices at another facility
Lesions Learned:
Should have taken the tPA bottle down from the IV pole and traced the line by taking out all of the twists in the line.
Should have also asked the respiratory person to move over so I could have made the changeover without obstruction.
Also double check that the people assisting with the change over are in fact holding the correct tubing.
Editors Comment:
This report again emphasizes the perils of multiple people working on one patient in a stressful environment with many distractions. The respiratory person blocking the view of the IV site and the non standard drip arrangement at the sending facility make this a difficult situation.
The other issues particularly post code is that there may well be too many people in the room. Too many people lead to too much confusion and many distractions. It might be possible to politely ask some to leave. Something like “Thank you for your help we can take it from here” or “ We can take it from here if you want to get started on your charting”.
Pilots have developed cockpit resource management techniques to limit errors and omissions. The foremost of these is the checklist. If there is a task to do, such as finding the end of the line at the IV site. We might want to consider this as an item on a checklist. It must be completed before moving on to the next task. Make no assumptions in completing the checklist! Another of these techniques is the scan, frequently checking the instrument panel in a systematic fashion. Developing a scan, by rechecking the drip rates and solutions every few minutes is one technique that should help prevent this situation from happening again.
An excellent and very comprehensive review of all thrombolytic agents is contained in the American Heart Association scientific statement at: www.americanheart.org/Scientific/statements/1999/AMI/edits/jac1716pVa.htm#rationale
Hopefully our lives will be simpler with the advent of Reteplase (Retevase) and Tenectaplase (TNKase) with their greatly simplified bolus dosing. But sorting out the multitudes of tubing on the critically ill patients will continue to be a challenge.
Scenario:
Transferred patient on Heparin and Dobutamine drips. Called for report prior to arrival and the RN at the sending facility was not sure of the drip concentrations or doses. On our arrival the EMT P switched over the drips from the facility’s pumps to ours at the same drip rates. Enroute the RN checked the drip and found the Heparin drip infusing at 20 cc/hr. There was no lab results, Heparin drip orders or nurses notes sent in the documentation with the patient. Called back to the sending facility and checked with the RN who stated that the drip was to infuse at 3cc/hr. Receiving facility was notified and the patient suffered no untoward effects.
Root Cause:
Gap (or failure) in the transfer of information from sending nurse to transport crew.
Limited time for chart review.
Lessons Learned:
(reporter’s own suggestions) Should have doubled checked the documentation sent with the patient to check for coag study results and standard Heparin orders. The patient’s chart should have been reviewed in greater detail in this situation, however this does cause an increase in bedside time. RN should have checked and verified drip rates prior to leaving and had the AM Coag studies.
Editorial Comment:
This case illustrates several issues. The obvious one is the failure of the information transfer between the two caregivers. This failure occurred at a gap in the continuity of care. A gap is a point where information has to transfer from one person or place to another. There is a high risk of losing or distorting this information as demonstrated in this account. Medical transport has many gaps. Usually these are filled by the good efforts of the staff involved. In this case the individuals involved were not able to bridge the gap in the system and an error occurred. Successful information transfer across these gaps is essential. The first step in preventing the failure across the gap is to recognize where it is, then assure that good communication occurs across the gap.
Again beware of drips and IV’s at other hospitals they may be very differentfrom what you are used to. This is our second error reported involving different IV drip setups. (see inadvertent tPA bolus). It is imperative to be fully aware of the solutions, piggy backs and drips on each IV. The checklist type approach would again, work well here. View this process as if completing a checklist. Start at each individual IV site starting at the needle and follow it back to the primary fluid, then to each piggybacks solution then finally to each drip. Note the solutions the rates and the concentrations on the form.
The other issue is one that plagues all areas of medicine and that is the management of huge amount of information in a paper chart. It is extremely difficult to find the essential features of a two week hospitalization out of a hospital chart in the allotted 30 minutes of bedside time.
What this case demonstrates most vividly, though, is the benefits of persistence in finding the needed information. The error had already occurred at the time we took over the care of the patient. Given the constraints on bedside time it was not immediately picked up. But by being persistent the crew very quickly noted that there was information missing and started working to find the information. By calling back to the sending hospital the morning PTT was obtained. The IV’s were also traced back and the drip rates and concentrations checked. All of this occurred very quickly and an error that had been perpetuated over days was identified and corrected within an hour and the patient suffered no injury.
For an excellent discussion on “Gaps” in the continuity of care see:
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
Scenario: Cared for patient post defibrilation who was unable to straighten the legs due to leg cramps. Treated with Versed 10mg, Valium 7.5mg and Robaxin 1gm IVPB. Received order to give Valium 2-5mg for leg cramps. Versed was actually given instead. The patient tolerated the meds without respiratory compromise and rested well. Pulse oxymetry maintained at 100%.
Root Cause: Error in identifying and administering the ordered medication. Failure to check the label against the order. Fatigue may have been a factor as the incident occurred at 05:00 after 17 hours on duty.
Lesions Learned: The bottles appear the same except for different colored caps. Possible solution suggested for avoiding the error would be keeping them together in a pouch carried by the RN.
Editors Comment: It is easy to confuse these two drugs the names and pharmacology (see Fig 1) are very similar and in this case, both were prescribed for this patient. Although the potential for serious injury existed fortunately in this case the patient was not injured. There are several considerations that may help prevent recurrence of this type of event in the future. One would be to possibly order medications by their generic names. It would be a lot more difficult to confuse Diazepam with Midazolam. Also checking labels several times is always helpful. A similar procedure is that of asking the patient or checking the allergy band prior to administering any medication. Before injecting, check the allergies, check the label! Particularly at times of stress or where fatigue may be a factor discussing orders and treatments with your partner might be very helpful. Work together to assure the order is both received correctly and administered as ordered. Also in this case the physician may have minimized confusion by staying with just one agent when the both are so similar.
We were dispatched to a suburb, (which should have been a 5-10 minute response) to transport a closed head injury. Patien was disoriented, combative with hematoma. Our dispatcher gave us directions that put us two townships away from the scene in the oposite direction. By the time we got to the scene, packaged the patient and worked him up and transported to the hospital he began to decompensate with increased BP, decreased LOC and multifocal PVCs. On arrival at ED pt had spontaneous respiration and had inappropriate answering of questions.
Several issues are at play here one is the dificulty of dealing with multiple jurisdictions and communities the other is communication between dispatcher, the responding units and the units on scene. All units need to be aware of where they are and are they meeting the expected response times.
One very effective solution to this that is frequently cost prohibitive is the use of GPS locating systems on the responding units. This allows real time monitoring of responces of the units. These would be wonderful to have but probably not realistic for most EMS ssytems.
The final factor to consider is that in areas experiencing rapid growth the geography and maps will be changing very rapidly. This will require careful attnetion to updates to the CAD (computer assisted dispatch) system and the protocols for response.
ALS was called to assist a fire brigade responding as first responders. They had administered glucose paste orally. The patient was lethargic with glucose of 60. The patient was unable to protect their airway and the paste was smeared around their face, arms and chest. The patient was treated with D50 IVP and became alert and oriented. There did not appear to suffer any injury or adverse effects.
This was certainly a near miss. The MEPARS editors in their comment centered around the need for continued emphasis in EMT and first responder training on the dangers of using any orally administered medications whether it is glucose, charcoal or tablets in a patient who is not alert and able to protect their airway. From a systems perspective providers of all levels should be thoroughly familiar with the adverse effects and indications of the agents that they carry.
This also might be an excellent case for discussion between the ALS crew and first responders, either through formal continuing education or in informal follow up. This would aid in the retention and application of information that had been learned earlier in first responder class and perhaps forgotten.
I applied CPAP to a patient in florid pulmonary edema. When turning the control to regulate the CPAP, it was discovered that the gauge was broken and would not move off of "0" In order to provide the patient with the level of treatment needed I continued using the CPAP unit and gauged how much PEEP to administer based on the patient’s improvement. Although I could not see a number to determine the amount of PEEP, the patient had marked improvement in just a matter of minutes. I continued the CPAP until arrival at the hospital where the patient was switched to their BiPAP unit.
There are several issues demonstrated here. First was there a company wide policy for periodically inspecting equipment and was the policy followed? Following proper procedure would also help answer the question of how long had it been malfunctioning. Was there a possibility of a second unit responding with a working unit?
Second, there is an inherent danger in using equipment that is not functioning correctly, particularly if the safety features aren’t working. While proceeding with CPAP might appear to be safe since high pressure gasses may simply leak under the mask, there have been two cases reported where pneumothorax may have been caused by prehospital use of high-pressure CPAP (1,2). We have seen other case where not heading safety devices has lead to dangerous events. (3) In general, safety devices do provide protection for the patient and bypassing them can be a dangerous practice.
1. Kosowski JM, et al, Prehospital Emergency Care. 5(2):190-6, 2001 Apr-Jun
2. Gregg RW, et al. Critical Care Medicine. 18(1):21-4, 1990 Jan
3. Out of Control Drips, www.mepars.com
We responded for a patient with fluid retention. I found an elderly patient sitting in a chair acutely dyspneic with bibasilar rales. I planned to administer 4ml (40mg) of Furosemide. I reached in to my drug bag and took what I thought was the Furosemide and began to administer. It seemed hard to push so I checked and it was 50% Magnesium Sulfate. I had pushed approximately 3.2 ml (1.6 gms). Both drugs are kept next to each other in identically sized boxes one is orange brown the other is orange. I clamped the extension tubing removed it and put a new one on. I withdrew the fluid in the primary set. The patient suffered no untoward effects.
Even an adverse event that would appear to be as simple as this one, are frequently the result of a chain of events. There are several latent causes for this event. One goes back to the manufacturer of the medications and their choice of colors for the labels. For example the manufacturers of ophthalmologic drops have color coded their labels to prevent confusion. Another cause is in the design of the medic’s bag and the drug placement there. It would be inevitable that two vials of similar color next to each other would be interchanged during prehospital care activities. Hence one remedy for this event would be to re-evaluate the medic’s bag with an eye towards how the drugs might be seen look in the dark or when acting rapidly. Another option might be to stock MgSO4 as a premixed bag in the section of the bag for IV infusions since Magnesium is usually used as a drip.
Tradition suggests that if at all possible two providers should confirm that the right drug and dose are being given to the right patient by the right route at the right time. While this would seem to make sense, patient safety expert believe this is not very effective.
Also note in this case the provider was using all of his/her senses while administering the drug. It felt thicker than expected and hence the error was discovered early and excellent recovery was made.
I responded to an apartment building for an elderly patient having chest pain. The patient lived alone and was unable to come open the door for us. The doorman and maintanance were not available either. Although there is a key access box (1) for entrance by emergency services into the building, EMS does not have access to it, only the fire department does. We had to wait 16 minutes for Fire Department response. While there was potential for patient injury due to this delay, this pt did not suffer any ill effect.
This incident points out the benfit of pre-planning for access to multiple dwelling buildings. In some jurisdictions, access to key acccess boxes is limited to fire department personel only. In these areas a fire company may need to be automatically dispatched with EMS. In other areas, it may be as simple as getting a copy of the keys to be carried with EMS. This case demonstrates how EMS can benefit from pre-planning building access. It is a really good idea to work out ahead of time with dispatch, your local firefighters and building management. Thanks for pointing this out.
(1) Key access box refers to a central device that holds keys to allow emergency workers access to many dwellings or offices in a building in one place under one key that is carried by emergency responders. They are often reffered to as Knox-boxes®, but there are other manufacturers. They come in many sizes and have many applications for both rural and urban sites.
Figure 1Key access devices come in multiple forms. These examples are made by Knox.
We were dispatched to hospital A to pick up patient to go to hospital B enroute we were informed that hospital B would not accept the patient. We were ordered to proceed to hospital A to help with preparations for transfer. We then sat in the waiting room at hospital A until bed clearance was obtained at hospital C. We then transported to hospital C.
Comment:
This scenario demonstrates that all components of the transfer, from dispatch to transfer must work together and continue to communicate in the completion of the mission.
This case does demonstrate one common type of system problem. That is that the desire to do good, complete the mission and save the life, can sometimes be overwhelming. This desire has caused many EMS professionals to start into dangerous conditions and make decisions that sometimes lead to disastrous consequences. This is the advantage of having strong guidelines of what is safe practice and rigidly following them.
MEPARS has received several cases involving incorrect drug dosing.
Pediatric traumatic arrest from massive head injury. We decided to treat with Epinephrine by the endotracheal route at 0.1mg/kg. We then changed plans and gave Epinephrine by the interosseous route, should have been 0.01 mg/kg.
We arrived to find patient that had been defibrillated by an out of hospital AED. We started Lidocaine drip, intending to give 2mg we set the pump up to deliver 15mg/hr instead of 15ml/hr…
Comment:
These cases are presented to emphasize the benefit of using aids to drug calculation. In the first case, particularly if you don’t do a lot of pediatric care, the use of PDA’s or Broslow tape or other reminder devices can be very beneficial. There is no shame in consulting a cheat sheet or device to help with dose calculations.
In the second case the benefit of using a pump with a dose calculator was demonstrated when the medic mentioned that they had to hold the controller button down forever to get to the dose they wanted. Remember that the pumps with calculators are set up to start at a standard dose. When you have to deviate from that dose it is time to pay careful attention to the dosing. If you are overriding a safety device it is time to rethink your plan.
Several reports received highlight the value of good communication skills.
.. the patient was post cardiac arrest and unable to straighten their legs due to cramping. We administered Versed, Valium and Robaxin. We then received an order for Valium and Versed was given inadvertently…
Patent was intubated due to CHF and on a versed drip. Patient was chewing on ET tube. Decision made to paralyze patient for transport. There were many distraught tearful family members at the bedside. In addition to paralysis with Vecuronium paralysis we inadvertently gave two 1mg doses of Morphine instead of two 1mg dose of Versed as ordered. The patient did not exhibit any adverse reactions. The error was discovered the next day during drug count.
Comment:
While there are frequently distractions during care of EMS patients i.e. family, or looking out for the gun or getting the patient out of the vehicle, we must work to minimize these distractions. Several lessons can be learned from the experience of aviation such as remembering that the crews are teams caring for the patient. We encourage everyone to take advantage of this fact and cross check actions with your partner. The military has researched this extensively and lists the components of effective communication at: http://wwwnt.cnet.navy.mil/crm/crm/stand_mat/seven_skills/CM.asp. An ideal scenario would be to call out “giving versed 5mg IVP” and have your partner confirm the versed dose and route. Then state “giving versed 5mg IVP”. Even if working solo this process will help reduce medication errors.
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