Medication Errors

Medication Errors

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.

Causes of errors vary and can include:

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. 

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

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. (

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!


The UH EMS-I Team

University Hospitals