March 28, 2025

Welcome to UH EMS-I’s Pharmacy Phriday. In the last installment, we discussed medication errors and the use of UH EMS-I’s Serious Incident Report (SIR) to report errors or near misses. Another tool available to providers to assist in preventing medication errors is the new OneDose™ application.

Before discussing this new tool, we want to share an issue reported to us about the QR code for UH EMS-I’s SIR. After the last installment, we received feedback that the QR code did not work. Please note: if you are using a personal device, scanning the QR code will prompt you to download the “SignNow” app before completing the form. However, if accessing the SIR through the link in the OneDose™ app, you will not need to download the app on your personal device.

If anyone is still having issues accessing the form, please be sure to reach out to your EMS Coordinator.

The OneDose™ Protocol Management Tool, a product of Hinkley Medical, is an application that has recently been made available to providers within the UH system. Monthly continuing education was provided in January of 2025 to introduce this new tool. If you missed the training, several resources are available to review its use, including the original CE program archived at the Prehospital Paradigm website (click here).

The OneDose™ app has many features that can be an integral part of our efforts to prevent medication errors. By entering actual or estimated weights, a patient’s age, or using the OneWeight™ scale (an additional feature that agencies can purchase), the app provides accurate medication doses and volumes specific to that patient. The OneWeight™ scale sends the patient’s weight from a cot scale directly to the app.

Dr. John Hill, one of UH’s Medical Directors puts it this way:

“OneDose™ enhances patient safety by ensuring that our EMS providers have immediate access to accurate dosing calculations, medication volumes, and appropriate equipment sizes,” said John B. Hill, MD, Emergency Medicine Physician and UH EMS Medical Director. “By removing guesswork and simplifying complex calculations in high-stress situations, OneDose facilitates rapid decision-making with confidence and accuracy.” 1

Some additional features of the application include:

• Access to the most current protocols

• Assistance in assuring protocol adherence

• Precise electrical energy calculations for defibrillation or cardioversion

• Correct equipment selection and sizes

• Age-appropriate vital signs reference

To access the app, users need a username and password. Usernames have been created for each department to use on shared department devices (iPads, tablets, phones, etc.). For personal device access, users need to create an account using the department code and PIN provided. Contact your department or hospital EMS coordinator/manager for your agency’s specific code and PIN.

Once you have set up the app on your device, be sure to practice using the tool. Just like any other piece of equipment, it is extremely important to use the app during training scenarios and drills to become familiar with its features and comfortable using it in high-stress situations. Set yourself up for success!

For more from Dr. Hill on the new OneDose™ application for UH providers, click here.

Additional training on the app is also available on the Hinckley Medical site here.

Until next time, stay safe!

Sincerely, 

The UH EMS-I Team 

University Hospitals 

Download a PDF of this email HERE.

1https://www.fireengineering.com/industry-news/university-hospitals-ems-introduces-onedose-protocol/

March 21, 2025

Welcome to UH EMS-I’s Pharmacy Phriday. Over the next few installments, we intend to focus not on specific medications, but on medication errors and some of the tools available to providers within the UH system to prevent these errors. 

Medication errors occur more often than one might think. One can do an internet search for  “Medication errors in EMS” and find numerous articles and resources addressing the issue. One study states it this way:

The evidence available suggests errors may occur in up to 12.76% of medication 

administrations in some prehospital settings. With multiple sources stating that the errors 

are under-reported, this represents significant potential for patient harm.1

If a medication error does occur, in the spirit of patient safety, the incident must be reported immediately to the receiving facility, documented on the PCR, and notification to the EMS Medical Director made. It is simply the right thing to do! 

In some cases, the error may be noticed and stopped prior to administration. This would be referred to as a near-miss incident. Reporting these cases can help to identify system-wide problems which can be fixed, or educational issues which can be shared for the benefit of all our providers and patients, reducing future errors. Medication errors and near misses can include but are not limited to dose-related errors, protocol errors, wrong route errors, and wrong medications. 

Reporting of near misses can be made directly to your EMS coordinators or Medical Directors. 

Within the UH system near-miss incidents can also be reported anonymously using the Serious Incident Report (SIR) which can be accessed by following the link that is provided within the protocol. A QR code is provided that can be used to access the report online (see figure above). A direct link is also available using the OneDoseTM application by typing “SIR” in the search bar then tapping on the QR code within the app. The user will be taken directly to the form. 

This form can also be used to report protocol errors or violations, protocol corrections that may be needed, clarification of specific algorithms, protocol suggestions or recommendations, injuries, hazards or conditions that can cause injury, medical equipment failures, delays in transfer of patients in the ED, and many other issues or concerns.  

When completing the form, the only required entries are an incident type and a description of the incident. Optional areas include recommendations for improvement, a provider name, the name of the department or agency, contact information (if feedback is requested), and the date of the incident. Not only can this be completed anonymously, but all information within the report is Quality Assurance/Peer Review privileged pursuant to the Ohio Revised Code.  

Until next time, stay safe! 

Sincerely, 

The UH EMS-I Team 

University Hospitals 

Sources:

1. Walker, Dennis et al. “Contributing factors that influence medication errors in the prehospital paramedic environment: a mixed-method systematic review protocol.” BMJ Open Vol. 9,12 e034094. 23 Dec. 2019, doi:10.1136/bmjopen-2019-034094

July 29, 2022

Dear Colleagues,

A patient is found unresponsive and in respiratory depression in the emergency department after using self-administered fentanyl patches before calling 911, having morphine administered by EMS, and receiving Dilaudid in the emergency room.  Providers failed to ascertain medication use by the patient during their assessment and history.

During a 911 call, paramedics administered morphine to a patient instead of the desired medication of epinephrine.  The error was due to similar size vials, look-alike labels, and identical cap colors.

A pediatric patient received twice as much Zofran as indicated in the EMS protocol when paramedics recalled incorrect dosing and were unable to refer to the protocols to confirm the dose.

In this week’s Pharmacy Phriday, the focus is on medication errors.  I am sure most recall hearing of the “Six Rights” of medication administration somewhere in their training.  Though they are common to us, they are also important to review on occasion.  Medication administration is a high-risk event in EMS and deserves a frequent review. 

Errors can and do occur and have the risk of causing great harm for the patient.  Various studies highlight the problem.

• Errors may occur in up to 12.76% of medication administrations in some prehospital settings. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008412/

• Approximately 1 in 5 reported EMS-related medication errors resulted in patient harm.· https://www.ismp.org/resources/analysis-paramedicine-medication-errors-uncovers-challenges-and-opportunities-improvement

• A survey in San Diego County found that 9.1% of responding paramedics reported committing a medication error over the previous 12 months. The types of errors included dose-related errors (63%), protocol errors (33%), and wrong medication errors (4%). https://www.ems1.com/medication-error/articles/can-we-do-more-to-reduce-medication-errors-5V1waStdnyVgWd5G/

Causes of errors vary and can include:

• verification issues

• the chaotic setting prehospital providers work in

• poor lighting

• dangerous environments

• fatigue

• the critical time-sensitive nature of emergency patient care

• the rapidly changing status of ill or injured patients

• medication storage issues

• appearance and labeling of medications just to name a few

Regardless of the cause, the provider must take responsibility to ensure medication errors are eliminated. 

Providers can take steps to prevent these errors, including using the “Six Rights” of medication administration learned in training. 

• Right patient – This is not usually a problem in the prehospital setting, except for maybe multi-casualty incidents.  More commonly, this area may relate to the medication right for the patient, i.e., allergy concerns, interactions with prescribed medications, or possible interaction with medications taken by the patient prior to EMS’s arrival on scene.

• Right medication- Packaging can often look similar on different medications.  Be sure to read the label.  It is often suggested the label be read three times, including when removing the medication from the box, as the medication is drawn up, and just before the medication is administered.  Do not be confused by similar-sounding medications either!

• Right dose – Efforts are often made to provide as many medications in single-dose units but are not always the case.  In cases when specific amounts must be drawn up (i.e., weight-based medications, administration for special population groups like pediatric or geriatric patients), be sure calculations are correct and drawn up correctly. Concentrations of the same medication can also cause errors. 

• Right route – ·Besides assuring a medication is being given via the route intended, remember that some medications can be given via multiple routes with different dosing and concentrations depending on the route.   Be sure the proper concentration is being used for the proper route!

• Right time – In the prehospital setting, most medications are given “stat”.  The provider must remember time as a critical element in cases of repeat doses or possible infusion rates. 

• Right documentation – Be sure to inform other providers and document any medications given to ensure the proper transition of care.  This may also include other medications the patient had taken prior to EMS’ arrival or prescribed medications affecting the patient’s care.

To avoid medication errors, the provider should also be aware of various tools and resources available to assist in those efforts.  These can include:

• Tall man lettering used in the labeling and reference of medications (i.e., LORazepam, diazePAM, as found in UH protocols) 

• Protocols and apps, as well as tools within those documents such as calculation features or pediatric weight-based dosing charts hyperlinked in the downloadable pdf from the UH EMS site 

• Browslow or other length-based tapes

• Printed reference materials in the squad

• And of course, your partner or medical direction; Many articles and documents stress the importance of a team concept in treating our patients and medication administration.  

An EMS system in Kansas developed and implemented a team-based communication protocol that focuses on the inclusion of others in the team to serve as a standardized method of medication verification to reduce errors. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351968/).

Other team models such as Crew Resource Management also stress the inclusion of the team in the making of critical decisions and be easily adapted to the EMS environment in the back of the squad.  Two sets of eyes, ears, and hands on the patient are better than one.

Such efforts cannot only lead to better patient outcomes but also protect the provider from needless errors and exposure to legal liability!  Safety for all should be the top priority!  Set yourself and your team up for success!

Sincerely,

The UH EMS-I Team

University Hospitals