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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As long as the human aspect is there mistakes will be made.  I feel very strongly about medication errors because it is a basic safety net that was drilled into everyone who has the ability to administer those meds to check, double check, and make damn sure you are giving the right thing.  I have no doubt in my mind I would be terminated for the same error in the service I work in.

 

My wife, RN/Paramedic, and I were discussing this over lunch a little while ago and she reminded me of an incident in the NICU of a large childrens hospital in Indianapolis.  The concentration of Heparin was changed by the pharmacy and one neonate was killed and another almost because the nurse failed to verify the drug before giving it.  Nurses were terminated as far as we could remember and even possibly had liscenses revoked.  Complacency and laziness is what causes medication errors.

 

Joe Paczkowski said:

John, do you think that errors and mistakes can be fully eliminated, or are they events that can never be fully prevented?
I was referring to the military's way of human error until proven otherwise instead of a fair and impartial investigation into the incident.

Rogue Medic said:

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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BIG SIGH!!

Shame another thread where the quotation magnet offers play by play analysis for evidence demand. One day a comment could be accepted at face value as an annecdotal understanding of a premis.

If one wishes to discuss error management in airline safety go to an airline forum. Leave those interested in discussing EMS matters to get on with it. 


John Shady said:The concentration of Heparin was changed by the pharmacy and one neonate was killed and another almost because the nurse failed to verify the drug before giving it.  Nurses were terminated as far as we could remember and even possibly had liscenses revoked.  Complacency and laziness is what causes medication errors.

If I recall that incident correctly, the pharmaceutical company took a ton of flak over that incident and redesigned the packaging completely. Having dealt with two different heparin concentrations in a lab setting (and in a capacity where increased concentrations wouldn't have mattered anyways), the difference in the packaging was a slightly darker box that the concentration was listed in. It definitely wasn't anything blatantly noticeable.

According to how your posts are written, redesigning the packaging to make the error less likely was completely unneeded and shouldn't have been considered. After all, everything is ultimately the fault of the provider.

The provider is responsible to look at the vial of medication and verify it's concentration.  Just because you carry the same drugs in the drug box does not mean they have not upped the amount you have by the concentration and either did not tell you or you missed that staff meeting.  Yes, it is ultimately the responsibility of the individual to ensure they are giving what they think they are.

 

You never give a med you have not verified by looking at the label, drawing yourself, and then looking at the label again.  You never spike a bag of fluid unless you have verified the fluid before you spike it and again before you start the infusion.  Those things were drilled in me at Fort Sam Houston, in my Advanced EMT class, and again in Pharmacology in Paramedic School.  I will use the words complacency and laziness again.  Complacency because it is in the same spot in the drug box it has always been, maybe the concentration is upped or the pharmacy mixed it up, it is on you when you push the plunger of the syringe.  Laziness because you never took the time to look because you have done this a hundred times.  The two medication errors I have seen came from the concentration changing and from not drawing up the medication and verifying it when it was one the nurse was not familiar with.

 

By your line of thinking and what you are saying, Michael Jackson's doctor is not at fault for using Propofol for an unlabled use because the packaging allowed him to do it...

Michael Jackson's physician is not at fault for using a drug in an off-label use because his medical license allows him to practice medicine without restriction. Heck, off-label use itself isn't illegal (how many ambulances are stocked with King airways? Using the King airway in emergencies is, at least back in 2009, an off labeled [source] ). Michael Jackson's physician is in a lot of trouble for doing it in a manifestly dangerous manner. A mistake and negligence is not the same thing. 

 

No one here is arguing that it is not ultimately the provider's responsibility. What is being argued is that, when possible, policies and engineering should be done in a manner to enhance safety. If possible you don't want to give providers the chance of making a mistake. Using your mindset, things like needleless systems or engineered safeties on IV catheters are useless investments because it's ultimately the provider's job not to stick themselves when starting IVs. 

The bag of Lidocaine is marked with great big letters saying Lidocaine if it is a prefilled one.  What more safety engineering do you need.  This is not about safety and procedures needed to ensure the right thing is done from a company standpoint.  This is about an individual messing up because they did not do what they were taught from day one.  The difference between him and you from what your portraying is that he was remorsful and owned up to his error ans you keep saying we need more safety engineering to prevent this.

 

You say we need something to ensure this is not repeated and I gave you an answer to that and it is something everyone of us is taught from day one.  No amount of engineering, or safety systems can take out the human factor when someone decides to cut corners.  I treated a soldier in Iraq that decided his plates were too heavy and put in magazines to make it look like he had plates in, too bad the bullet didn't care he did not like the weight.  Results of his decision were pretty clear, he died.  Now all the safety mechanisms, including checks by the team leader, were in place but, he fooled everyone up to the point of the bullet ripping through his lung and aorta.  Human error and only preventable if he chose to prevent it by following the standards that were there.  I am not at all saying those things you listed are not important, I am saying medication errors are not the result of any of that when the provider does not follow the basics of the patients rights of drug administration.  Skip one of the steps of right patient, right dose, right time, right drug, or right route and anything prior to it is useless.  Short of removing the employee from practice there is no other safety mechanism that can be engineered to prevent poor judgment.

Joe Paczkowski said:

Michael Jackson's physician is not at fault for using a drug in an off-label use because his medical license allows him to practice medicine without restriction. Heck, off-label use itself isn't illegal (how many ambulances are stocked with King airways? Using the King airway in emergencies is, at least back in 2009, an off labeled [source] ). Michael Jackson's physician is in a lot of trouble for doing it in a manifestly dangerous manner. A mistake and negligence is not the same thing. 

 

No one here is arguing that it is not ultimately the provider's responsibility. What is being argued is that, when possible, policies and engineering should be done in a manner to enhance safety. If possible you don't want to give providers the chance of making a mistake. Using your mindset, things like needleless systems or engineered safeties on IV catheters are useless investments because it's ultimately the provider's job not to stick themselves when starting IVs. 

John Shady,

 

I was referring to the military's way of human error until proven otherwise instead of a fair and impartial investigation into the incident.

 

So the military does not does not make systems safer as long as they can find a human error?

 

I don't believe you.

 

We could just as easily point to any other place in the chain of events and say, If not for this, there is no error. As long as we only address one part of the problem and make that one point the only protection for the patient, we are encouraging dangerous practices.

 

Why do things to make the system safer, when we can focus on the individual and ignore the possibility for a significant improvement in safety?

 

If addressing system problems could lead to an 83% decrease in fatalities, and I choose to ignore it, how am I any less at fault than the medic who chose not to check a label?

 

As long as we ignore important systemic safety improvements patients will die.

 

Again, since you seem to confuse fixing systemic problems with a get out of jail free card for the medic, nobody is claiming that the medic should not be held accountable.

 

Nobody.

 

Some of us are stating that the medic is not the only one who is accountable. 

 

In a perfect world, there would not even be mistakes made by the medic. In a perfect world for administrators, administrative problems would not have lethal consequences and only minions would be accountable.

 

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No, they hang the pilot out to dry then say oops, sorry about that, we found a mechanical problem....

 

I am at a loss for what could have been done in this situation to improve safety and prevent this error so please enlighten me as to how the service or administration or doc is responsible for a lack of safety practices and lidocaine being infused instead of saline because of this...


Rogue Medic said:

John Shady,

 

I was referring to the military's way of human error until proven otherwise instead of a fair and impartial investigation into the incident.

 

So the military does not does not make systems safer as long as they can find a human error?

 

I don't believe you.

 

John Shady,

 

I am at a loss for what could have been done in this situation to improve safety and prevent this error so please enlighten me as to how the service or administration or doc is responsible for a lack of safety practices and lidocaine being infused instead of saline because of this...

 

We do not have all of the information. It would be a mistake to presume otherwise.

 

Why assume that because you, who have been claiming that we should not even consider any other contributory cause, cannot think of any contributory cause, there must not be any?

 

If you had looked at the commercial airline fatalities before the 83% improvement in fatalities, but you only looked at a couple of news articles about a single crash, would you have identified the changes that would have cut fatalities just from a couple of articles in the news?

 

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John Shady said:

I am at a loss for what could have been done in this situation to improve safety and prevent this error so please enlighten me as to how the service or administration or doc is responsible for a lack of safety practices and lidocaine being infused instead of saline because of this...

Well, answering this question is going to require a few assumptions, since I don't know all the details required. However, based on the assumption that this mistake could only happen because the medic would have found the lido in a place where he was looking for saline, merely not stocking medicated solutions next to saline would be a service practice that would have prevented this. (The best place, of course--and this is where the doc comes in--would have been not on the truck at all, since there is really no call to give anybody a lidocaine drip.) In other words, if they would have merely made their ambulance look like every ambulance I've ever worked on....

I agree with DrX - the error would have been avoided if the agency's protocols had been based on medical evidence.  There would have been no pre-mixed lidocaine on board, and thus the possibility of THIS error would have been reduced by 100%.

 

If you MUST have medications that are packaged alike, how about a bright red label, or something else prominent, to distinguish one from another (the useless one from the other useless one?)?

 

As an editorial comment, my experience is that hospital operated services, or those services where drugs are exchanged or provided by hospitals, are the worst in this area.  They change vendors, and thus drug packaging, at random, unannounced moments - thus today, epi is in the long skinny red box, while zofran is in the short fat brown vial.  Tomorrow, they are reversed.  Yes, you should read, double read, and read back the drug labels with two people, but (surprise) sometimes that doesn't happen.  How about engineering to reduce the probability of errors on the front end?  One of our efforts has been to standardize the "blue bag" on every ambulance and other response vehicle in the system, so that when you grab somebody else's bag, things are where you think they will be.

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