http://www.wrcbtv.com/story/15461192/hamilton-county-paramedic-susp...

 

"A passer-by found Melvin Davis dangling from his ankle in Hixson. He'd been there for two days.

When EMS responded, they hooked up two IVs, but one was the wrong IV. When he arrived at Erlanger doctors immediately alerted EMS headquarters of the mistake."

 

 

 

"Hamilton County EMS Chief Ken Wilkerson said, "I've been with Hamilton County EMS for almost 24 years now, and this is the first time I've ever had to deal with a situation like this."

With 29,000 calls a year Chief Wilkerson says a mistake like this is as rare as it gets."

 

Really???  "as rare as it gets??"   I dont think medication errors are that rare.

 

"Chief Wilkerson wouldn't tell us what was in the wrong IV, but the first responder who hooked it up, Tim Waldo, has been suspended without pay for 28 days, and has been demoted from Paramedic to EMT."

 

Im not sure how I feel about this.  Is this encouraging honesty?  Is it encouraging a healthy work environment?  Its definitely something that needs to be addressed, but is this the right way?

 

 

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John Shady,

 

The NREMT exam is a joke. It is cheap and fast and . . . . . . Oops, I forgot. We only get to pick two. Cheap, fast, and excellent do not go together, no matter how well it might be packaged to convince the rubes otherwise. They do seem to be trying to improve, but they have a long way to go.

 

If a soldier makes a big mistake, his NCO is not going to have some explaining to do?

 

Likewise, the officers up the chain of command.

 

Really?

 

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Rogue Medic,

 

OK, OK, I'll change my ensure to give an attempt to show competency.  Still the same principle...

 

You and a lot of other people make it sound like it is Ok to pass the blame.  The buck stops with the individual who grabs and releases the clamp on an IV line or hits start on the pump.  I have been trained to look at a bag of fluid to verify it is correct, not expired, etc.  I have been trained to the patient's rights concerning medication administration.  Unless you can show me where this medic was not trained to those things I will not pass the blame on the service or administration.  I said initially the punishment is harsh and over the top.

 

To answer your question, If a soldier made a mistake of their own personal choice I was not held responsible nor was any officer.  If the screwup was a result of a lot of little things that had never been addressed or a lack of training, yes i would have been held responsible.  Had plenty of them get DUIs and other variouse criminal charges, fail drug tests and the such.  Individuals are responsible for their own actions.

John Shady,

 

To answer your question, If a soldier made a mistake of their own personal choice I was not held responsible nor was any officer.

 

Why do you assume that this is just the individual medic, without knowing any of the details?

 

Individuals are responsible for their own actions.

 

Individuals are responsible for their own actions, including when they supervise others.

 

We still do not really know the details of this, except for the punishment and the name of the medic and the name of the patient. Isn't it a bit backwards to be putting a lot of this information out there, but not any of the details of the error. 

 

The patient's name? - Here you go.

 

The treatment given? - Here is some of that information.

 

What exactly happened? - Whoa! HIPAA! We can't tell you that!

 

If one of your soldiers did something wrong, you would expect to be asked about it by at least one officer. If you start by giving a lot of details that are unimportant, isn't that going to raise some questions about why you are answering that way?

 

Nobody has stated that this medic is not responsible for his actions, but we are pointing out that there should be an examination of ways to prevent these errors. The company does not appear to have even considered that approach.

 

Have there been similar errors with this company?

 

Have there been similar near miss errors?

 

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John Shady said:

 As my Drill Sgt. used to say in basic, "Excuses are like butt cracks, everyone's got one and they all stink." 


Yet, if you don't learn he reasons behind mistakes, you can't correct them. The provider should be one line of defense, not the only line of defense.


John Shady said:

You and a lot of other people make it sound like it is Ok to pass the blame. 

 

Pass and appropriately share the blame are two different things.

The buck stops with the individual who grabs and releases the clamp on an IV line or hits start on the pump. 

No. The buck is shared by those who enabled a situation to occur that increases the chance of a mistake occurring. Ensuring that a mistake doesn't occur, through a combination of engineering, training, and oversight, is more important than simply passing the buck to the last line of defense.

Individuals are responsible for their own actions.

Are individuals responsible for inaction as well?

Joe,

 

Well then maybe they should suspend the supply clerk that ordered the bag of premixed Lidocaine too, or just go BLS so there are no medications to make an error with...

 

That line of thinking, and I am specifically addressing the medication error, is why we have them.  Until everyone says that "the responsibility is mine and only mine when I give a medication", including NS, we will have mistakes.

 

 



Joe Paczkowski said:


John Shady said:

 As my Drill Sgt. used to say in basic, "Excuses are like butt cracks, everyone's got one and they all stink." 


Yet, if you don't learn he reasons behind mistakes, you can't correct them. The provider should be one line of defense, not the only line of defense.
The reason is he failed to verify the fluid he started...and the only reason

Perhaps your Drill Sgt. should be placed in charge of investigating aviation accidents.

I was in avaition for a number of years and a deployment, no one will ever change that cluster of a system...

Tom Bouthillet said:

Perhaps your Drill Sgt. should be placed in charge of investigating aviation accidents.

 

 

Or to paramedic.  :)

Mike Rubin said:
"Demoted from paramedic to EMT." Interesting concept. Maybe docs who make mistakes should be demoted to nurses...or at least podiatrists  :-)
John, do you think that errors and mistakes can be fully eliminated, or are they events that can never be fully prevented?

John Shady,

 

I was in avaition for a number of years and a deployment, no one will ever change that cluster of a system...

 

From Wikipedia, but this does not have a link to the original source of the information. Therefore, I am not able to tell where this is from. If anyone is familiar with the data, please provide something with links to a source. Were they just starting from a really bad year, or were they using something like a ten year average?

 

The Commercial Aviation Safety Team was founded in 1998 with a goal to reduce the fixed-wing commercial aviation fatality rate in the United States by 80 percent by 2007. By 2007 CAST was able to report that by implementing safety enhancements, the fatality rate of commercial air travel in the United States was reduced by 83 percent.

 

Is this improvement correct, that addressing commercial aviation safety resulted in an 83% drop in fatalities?

 

I do not see why you would claim that airline safety cannot be changed or has not been changed.

 

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