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Top 10 Things You Need to Know to Reduce Medication Errors

Kim D. McKenna MEd, RN, EMT-P

Medication errors are common in the field. These 10 tips can help EMS providers ensure they avoid administering the wrong medication or the wrong dose.

Introduction

Within the past five years, leading EMS organizations in both the U.S. and Canada have issued reports that identify patient safety as a priority in the industry. In both cases, medication errors have been determined to be an area in which improvement of safety is needed.1,2

The environment paramedics practice in is ripe for medication errors. The Institute of Medicine defines an error as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim.”3 Factors in EMS practice similar to those in emergency medicine increase the risk of making an error. In the prehospital setting, high-risk medications are given with intense time pressure with limited clinical information about the patient because of the emergent nature of the patient. Paramedics administer medication in unfavorable environmental conditions, which include excessive noise, distractions and poor light. In addition, providers often have no onsite medical direction to verify the proper dose.4 This already risky setting is compounded by the drug shortage, which has required frequent substitution of specific drugs or the manner and strength in which drugs are supplied.

In a study of self-reported medication errors by California paramedics, researchers found that 9% of the participants reported a drug error within the past 12 months.5 In 2012, researchers confirmed the prevalence when they looked at medication administration in patients who arrived to the emergency department by ambulance. They found a 12.7% incidence of medication error, particularly in patients who received more than one drug or in those with long transport times.6 Although they did not explain this, it may relate to their finding that when more medications were administered, the risk of error was higher.

Pediatric patients are not immune from this epidemic of error. In 2006, researchers found that 65.8% of pediatric epinephrine doses in Los Angeles County were incorrect.7 In an attempt to combat this problem, their system mandated use of the Broselow length-based pediatric tape. They also implemented team-based care and a quality improvement program. Even with these changes, this number only improved to 35%. Researchers confirmed this in 2010 in paramedic pediatric simulations when they found epinephrine was administered incorrectly in 69% of the cardiac arrest and in 75% of the asthma scenarios.8 Results in a 2012 Michigan study of pediatric drug administration were even more astounding; researchers found that a medication error occurred in 35% of children who were given a medication and had a weight recorded.9 In their study, more than 60% of epinephrine doses were incorrect.

The evidence clearly shows a problem, so it is important to ask: How can EMS providers minimize the risk of drug dose error? What can paramedics and their EMS systems do to correct it?

 

1. Six Rights

First, follow the six rights of drug administration. This includes giving:

  1. The right drug;
  2. At the right dose;
  3. At the right time (and time interval);
  4. By the right route;
  5. To the right patient; and
  6. Followed by the right documentation.

These steps have been at the root of drug administration safety since EMS began, and they remain as the foundation of proper medication administration today. Yet they only provide the foundation, the first of our top 10, because even though this step is at the top of our list for medication safety, it has not proven to be a sufficient barrier to prevent medication error by itself. This is because the process of going through these steps can become routine. Even well-meaning, diligent paramedics may think they are giving the right drug, yet be fooled by cognitive error, which is a way that our mind convinces us of something that isn't really true.

 

2. Formal System

Next, use a formal system to double-check medications before administration. For example, Sedgwick County EMS in Kansas, implemented a formal system called the Medication Administration Cross-Check (MACC) to reduce medication administration errors. This standardized procedure is required for every medication administration.

Provider #1 calculates the drug dose and draws it up. They then must stop and say out loud, “Med check.”

Provider #2 must then confirm by stating, “Ready.”

Provider #1 then states the drug name, dose, route, rate and reason for administering.

Provider #2 considers this information and, if they have no concerns, they ask, “Contraindications?”

Provider #1 reconsiders possible contraindications. If none are present, they reply, “No contraindications.”

Provider #2 then inquires, “Volume?”

Provider #1 shows the vial and states the drug concentration and volume to be administered.

Provider #2 considers this and, when satisfied that it is safe to administer the drug, they state, “Sounds good. Give it.”10

 

3. Use Your Voice

Repeat back verbal orders. Restating the order is a simple measure that can avoid an error having major consequences. For example, the physician on the telephone says, “Administer two milligrams of morphine.” The paramedic student hears, “Administer 10 milligrams of morphine” and administers that amount. Merely restating the dose would have alerted the student, the preceptor and the physician that the student had misinterpreted the dose.

 

4. Decision Aids

Use decision aids or support to help with drug administration. The medical literature has supported aids to reduce errors in administration for quite some time.3,7,11 EMS must implement these aids to reduce the incidence of error. Decision aids must be readily available, and the EMS crew must have practiced using them to be most effective. These aids include such things as pediatric length-based tapes like the Broselow-Luten tape, dosing decision support with algorithms and charts that have pre-established volumes calculated based on dose, and electronic dosing aids.1

 

5. Label Syringes

Do not administer medications from unlabeled syringes that you have not just prepared yourself. It is tempting to administer an unlabeled drug that your preceptor, partner or another trusted provider and co-worker has drawn up. But this practice has proven to result in serious medication errors.12 The American Nurses Association surveyed their members and discovered that 68% who responded felt that proper labeling of syringes could reduce errors. Despite this, only one-third said they label syringes all the time.13

 

6. High-Intensity Scenarios

Practice dose calculation in high-intensity, team-based scenarios. Practice makes perfect, so practice often. This is particularly true when administering drugs to pediatric patients where paramedics feel lack of exposure and training leads to errors.14 Practice, using the actual equipment you will use on the ambulance. This will allow you to sort through how to draw up small doses of medications for infants from adult-sized vials. Trying to do this on a critical pediatric call can increase your chance of error.7,15,16

 

7. Just Culture

Create an EMS system that promotes a Just Culture. The Just Culture is an approach to safety in the work environment that is built on the safety lessons learned in the airline industry. It assumes that paramedics are humans who, despite their best efforts to practice in a safe and mindful manner, sometimes make errors. The Just Culture advocates a standardized approach to error investigation and mitigation—regardless of the patient outcome.

Just Culture assumes that humans, despite their best intentions to do the right thing, will make errors. Organizations who embrace the Just Culture investigate adverse drug events thoroughly and, if there was a human error, counsel the person. If the error resulted from at-risk behavior, they coach the person. If the error resulted from reckless behavior, they punish the person. This promotes a culture in which paramedics feel empowered to report errors and near-misses, (situations in which an error is caught before the drug is given).1,17

With that approach, the root cause of errors can be determined before harm to a patient occurs. Additionally, barriers can be created to prevent a similar error from occurring in the future. For this approach to work, employees must feel confident that reporting an error will not result in swift and serious discipline, but rather thoughtful inquiry of cause. Just Culture achieves safety by balancing accountability between systems where no one is ever held responsible and a punitive one with immediate and severe discipline or termination.

 

8. Drug Bag Set Up

Set up the ambulance and drug bag thoughtfully to minimize the risk of error. For example, avoid putting “look alike” drugs in close proximity—or change the appearance of one of the medications to prevent someone from inadvertently picking up the wrong one.18

 

9. Get Your Zs

Be rested to safely do the job. A 2009 study of medical interns who switched from 30-hour shifts to 16-hour shifts found a significant decrease in medical errors.19 Looking at the relationship between fatigue and safety in EMS, researchers found that EMS providers who reported poor sleep were 50% more likely to report a medication error in the previous three months than those who did not.20 That same study found the odds of making an error were double in EMS workers who were fatigued as compared to those who were not.

 

10. Transport Patient Medications

Any time a patient moves from one location to another, there is a chance that errors will be made. Often the patient’s home medication list is not kept up to date. To reduce the chance that missing or incorrect information on the patient’s medicine list will cause an error, bring patient medications to the hospital. Although this action may not reduce the number of errors made in the field, an Australian study found that transporting the patient’s medications reduced the incidence of incorrectly prescribed medicines in the ED for the patients involved by more than 10%.21

 

Conclusion

Paramedics are human, and humans are not perfect. Nonetheless, making a medication error, regardless of the cause, can be devastating for the patient, the paramedic and the EMS system. Taking a moment to follow best practices in medication administration can help reduce your risk of making an error. If an error happens, the best action to mitigate any possible damage is to report it, however difficult that may be. Immediate reporting can help protect the patient. Reporting errors and near-misses also gives your agency the opportunity to investigate so they can determine if system flaws may have contributed to your adverse event. This, in turn, can allow them to fix those flaws and prevent others from being vulnerable and making the same mistake.

 

References

  1. Bigham BL, Bull E, Morrison M, Burgess R, Maher J, Brooks SC, Morrison LJ. Patient safety in emergency medical services: Executive summary and recommendations from the Niagara Summit. CJEM. 2011 Jan;13(1):13-8. doi: 10.2310/8000.2011.100232
  2. National Highway Traffic Safety Administration, Health Resources and Services Administration EMS for Children, & American College of Emergency Physicians. (2013). Strategy for a National EMS Culture of Safety.
  3. In Corrigan JM, Donaldson MS, Kohn LT (Eds.). Institute of Medicine & Committee on Quality of Health Care in America. (2000). To err is human: Building a safer health system. Washington DC: National Academy of Sciences.
  4. Croskerry P, Sinclair D. Emergency medicine: A practice prone to error? CJEM. 2001 Oct;3(4):271-6.
  5. Vilke GM, Tornabene SV, Stepanski B, Shipp HE, Ray LU, Metz MA, Vroman D, Anderson M, Murrin P, Davis DP, Harley J. Paramedic self-reported medication errors. Prehosp Emerg Care. 2007 Jan-Mar;11(1):80-4.
  6. Lifshitz AE, Goldstein LH, Sharist M, Strugo R, Asulin E, Bar Haim S, Feigenberg Z, Berkovitch M, Kozer E. Medication prescribing errors in the prehospital setting and In the ED. Am J Emerg Med. 2012 Jun;30(5):726-31. doi: 10.1016/j.ajem.2011.04.023. Epub 2011 Jul 8.
  7. Kaji AH, Gausche-Hill M, Conrad H, Young KD, Koenig WJ, Dorsey E, Lewis RJ. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006 Oct;118(4):1493-500.
  8. Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based assessment of paramedic pediatric resuscitation skills. Prehosp Emerg Care. 2009 Jul-Sep;13(3):345-56. doi: 10.1080/10903120802706161.
  9. Hoyle JD, Davis AT, Putman KK, Trytko JA, Fales WD. Medication dosing errors in pediatric patients treated by emergency medical services. Prehosp Emerg Care. 2012 Jan-Mar;16(1):59-66. doi: 10.3109/10903127.2011.614043. Epub 2011 Oct 14.
  10. Plumlee R. (2013, May 4). Sedgwick County EMS develops process to reduce medication errors. The Wichita Eagle. Retrieved Sept. 29, 2013, from http://www.kansas.com/2013/05/04/2789482/sedgwick-co-ems-develops-process.html
  11. Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care. 2008 Oct-Dec;12(4):486-94. doi: 10.1080/10903120802290752.
  12. Institute for Safe Medication Practices. Cutting errors out of the operating room: Part II. ISMP Medication Safety Alert! 2002;7(6)
  13. American Nurses Association. (2007, June 18) Medication errors and syringe safety are top concerns for nurses according to a new national study. Retrieved from www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2007/SyringeSafetyStudy.aspx.
  14. Fairbanks RJ, Crittenden CN, O'Gara KG, Wilson MA, Pennington EC, Chin NP, Shah MN. Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: An ethnographic view. Acad Emerg Med. 2008 Jul;15(7):633-40.
  15. Levine SR, Cohen MR, Blanchard NR, Frederico F, Magelli M, Lomax C, Greiner G, Poole RL, Lee CKK, Lesko A. Guidelines for preventing medical errors in pediatrics. J Pediatr Pharmacol Ther. 2001;6;427-43.
  16. Cottrell EK, O'Brien K, Curry M, Meckler GD, Engle PP, Jui J, Summers C, Lambert W, Guise JM. Understanding safety in prehospital emergency medical services for children. Prehosp Emerg Care. 2014 Jul-Sep;18(3):350-8. doi: 10.3109/10903127.2013.869640. Epub 2014 Mar 26.
  17. Just Culture. [Internet]. Getting to Know Just Culture. Outcome Engenuity; [2014 Feb 18; cited 2015 Mar 18]. Wise, D; [about 9 screens.] Available from: https://www.justculture.org/getting-to-know-just-culture/
  18. Kupas DF, Shayhorn MA, Green P, Payton TF. Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors. Prehosp Emerg Care. 2012 Jan-Mar;16(1):67-75. doi: 10.3109/10903127.2011.621046. Epub 2011 Oct 28.
  19. Blosser F. Medical errors decreased when work schedules for interns were limited, NIOSH- and AHRQ-funded studies find. [Internet] Atlanta: Centers for Disease Control and Prevention National Institute for Occupational Safety and Health (NIOSH). 2009 Feb 13 [cited 2013 Sept 29]. Available from http://www.cdc.gov/niosh/updates/upd-10-28-04.html
  20. Patterson PD, Weaver MD, Frank RC, Warner CW, Martin-Gill C, Guyette FX, Fairbanks RJ, Hubble MW, Songer TJ, Callaway CW, Kelsey SF, Hostler D. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehosp Emerg Care. 2012 Jan-Mar;16(1):86-97. doi: 10.3109/10903127.2011.616261. Epub 2011 Oct 24.
  21. Chan EW, Taylor SE, Marriott J, Barger B. An intervention to encourage ambulance paramedics to bring patients’ own medications to the ED: Impact on medications brought in and prescribing errors. Emerg Med Australas. 2010 Apr;22(2):151-8. doi: 10.1111/j.1742-6723.2010.01273.x.

 

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Published: March 26, 2015
Revised: November 27, 2015