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