I went to the bank yesterday to deposit a couple of checks. I fumbled my way through the process of filling out the deposit slip; I hadn't slept well the previous night, and my dog compounded the problem by absolutely INSISTING that he had to go outside for his morning routine of pee, sniff around, poop, pee, sniff around some more....you get the idea. Anyway...when I took the checks and slip to the teller, she thankfully double-checked my math with a calculator and discovered that I had screwed up my addition, shorting myself $200. Needless to say, I was grateful!
Now sitting in my office after a much better night's sleep, I'm struck by how the events of yesterday are similar to the circumstances surrounding medication errors in the ambulance. I've made a few myself in the years I've been working, and occasionally a student will pop in to tell me about a medication error that they made or observed during internship or clinical settings. I know that the possibility of error will always be present, no matter how mistake-proof we try to make the process. However, many efforts that I've seen hospitals take to reduce the incidence of medication errors haven't found their way onto many ambulances yet.
Why is that? Is it a matter of ego, improper education, apathy? Or some mix of all three?
Here are some ways we can start working from the ground-up to reduce medication errors in EMS:
As Providers
Double-check everything. Using the 6 Rights of medication administration is great if you're operating at 100% mentally; however, lots of things "make sense" at 0300 and ONLY 0300! The aviation industry got it right....they have a procedure called a "crosscheck" where multiple professionals check critical safety functions on an aircraft prior to it leaving the ground. A friend of mine who works in Kansas recently told me about a "Medication Administration Cross Check" that his service implemented:
http://vimeo.com/wscomd/review/40680029/9b7a58c827
Use a calculator. Nobody should have to rely on mental math in a critical situation; with all the weight-based medications we use, plus converting from pounds to kilograms, forgetting to carry the one can have significant consequences. I keep a small calculator in my fanny pack at work (I'm old-fashioned and nerdy that way), and won't hesitate at all to whip it out if needed.
Make infusion rate tables. Again, nobody should have to do a dopamine drip on the fly in a critical situation. Using a calculator can help you carry the one and keep your decimal places straight, but only if you remember the formula. I got around this by making infusion tables for every drip (weight-based or not) we would potentially use at our service. Each one has an abbreviated list of indications (the infusion rates for epi in symptomatic bradycardia are different from post-ROSC!), mixing instructions (you just can't print one off the internet and stick it on the truck....what if your dopamine vial isn't 1200mg/mL like they are in the hospital pharmacy that created the sheet, or you don't have 100mL aliquots of D5W to dilute it in?), and a table with adult weights. Laminate 'em and attach them to your infusion pump.
Bonus tip; if your service doesn't have infusion pumps (like mine), buy a small metronome and keep it stashed with your calculator. Setting a tempo that equals your gtt/min is far easier than trying to glance back and forth between your watch and the drip chamber.
Keep a medication reference handy. It's easy to forget the subtle differences between medications at times; even pharmacists screw up. Know what they always have laying around in the pharmacy? A medication guide with names, indications/contraindications, dosages, etc. If you're in a situation where there's no one else to cross check your medication administration, double-checking it in the book (protocol or otherwise) is a sign of wisdom, not wussiness. I particularly love the pocket-sized medication references because they're so portable, and they really come in handy if I encounter a prescription medication I'm not familiar with ("Paracetomoxyfrusebendroneomycin? Let me just look that up....").
As Educators
I think that we EMS educators have to shoulder some of the blame for all these medication errors....when I went through paramedic school, I was scared stiff that if I didn't have all 60 medication doses and concentrations memorized waking/sleeping/sober/drunk, our medical director would castrate me, take away my birthday, and use my EMT certification to bow his nose before using a small C4 charge to.....OK, maybe I exaggerate. But the fact is that if we truly want our students to administer medications safely, we need to take a hard look at how we're teaching them.
Use appropriate testing techniques. I don't think there's anything wrong at all with requiring students to know the formula for calculating a dopamine drip or similar infusion...but requiring students to do it on the fly during an ACLS Megacode is just asking for mistakes and student meltdowns! (Incidentally, the AHA seems to agree...they specifically state in their instructor manual that students are permitted to use their ECC Handbook to check a drug dosage) Leave the calculations to written exams or low-stress learning activities. Actually, in my most recent ACLS class I gave students blank infusion rate tables and had them fill them out. It's amazing how the formula sticks with you after calculating it 40 or 50 times....
Train the way you fight. Incorporate all the tips above into your small group simulations. There's a great quote I'll attribute to David Grossman, author of "On Combat" (which is a stellar book on how humans perform under stress); "We don't rise to the occasion, we sink to our level of training". I can preach all I want to about crosschecks and medication references, but if we don't expect our students to utilize those techniques during class, what should we really expect them to do in the field?
And will that really be best for the patient?
