Are medical errors in EMS rampant?

[Veneficus]

While it is no secret that I cannot type or spell, I can read. Today I was reading my assignment: Surgical patient safety.

For the purpose of brevity, I will not type out everything the text has to say about it, but I came across a very strange fact that set off some thinking.

Brennan et al. did a study on medical negligence. They defined adverse events as and injury caused by medical management that prolonged hospitalization, produced disability at time of discharge, or both.

In their study of 30,121 random patients, ovverall adverse events came to 3.7%

A companion study by Leape et al. revealed 19% of adverse events were medication errors. (Remeber that oxygen is a drug and all drugs are poisons, more on this later)

Diagnostic, noninvasive theraputic, and emergency department events produced most of the negligent complications.

Categories of errors include Diagnostic, treatment, preventative, and "other"

In the treatment category I would like to focus on:

Inappropriate (not indicated) care. It is also summarized as "errors in judgement."

This basically means that treatments that are not needed are erroneous. Think about it, 19% of medical errors are medications, oxygen is a medication, and it is often provided in EMS when not indicated. Since EMS was not part of these hospital studies, it would seem the percentage of errors could be considerably higher.

Let's now add on cardiac arrest medications when an identifiable pathology that is treated by the medication cannot be found, equals more medication errors by overtreatment.

Add on other treatments which are being demonstrated as not helpful or used excessively like spine boards (not to be confused with motion restriction or stabilization) and we haven't even considerd errors in the technique issues for things like ETT.

How about IV starts? How many are really medically indicated?

These are examples just off the top of my head. Can you think of any others?

Now I know that because of the nature of emergency medicine, standardized treatment algorythms have to be put in place to avoid not performing timely treatment and getting too caught up in diagnostics.

This obviously gives way to significant overtreatment. So what right?

Remember at the top of this page that emergency department events was among the major causes of medical error? How much of that is attributable to prehospital care? If we were to count it, it would make the numbers look considerably worse.

Here are some interesting figures:

Medical errors are the 8th leading cause of death in the US.

At a cost of 17-29 billion dollars a year. (that's 17,000,000,000-29,000,000,000) That is potentially more than all the profit in 2011 worldwide by drug companies by almost double.

***remember this does not take into account the numbers from EMS*** Which would make these numbers higher.

How much is being charged for an Ambulance or air medical unit in the US right now?

Does it seem that a lot of treatment that is not medically indicated, aka medical errors, are being performed?

How much of that overtreatment and therefore billing is going into your pocket? (I am guessing probably none. It is even be taking money out of your pocket.)

Does it seem like perhaps in order to reduce medical errors, save money, and not be negligent in the care of patients that perhaps more focused assessments and treatments need to be the future goal of US EMS?

Does it seem to you like not actively reveiwing and revising the common treatments in EMS perpetuates a culture of negligence and waste?

Does it seem like "following protocol" is going to be an affirmitive defense if a host of experts can say that the very protocol is negligent?

Put another way, if somebody ordered you to perform a treatment on a patient that you knew was unnecessary, would you think you had a duty to not perform said treatment?

How do you justify obvious overtreatment as something other than fraud? Especially if somebody or the government is getting the bill. How is it not fraud to count the cost of overtreatment in operating expenses?

Interesting questions I think.

 

[mycrofft]

I mostly reply "YES".

You're playing my tune.
I see some avenues to overtreatments and elevated "error" rates in EMS (street intake to emergency department discharge):
1. Lowest Common Denominator (e.g., "stoopid technician") Syndrome, where protocols dictate mandatory treatments as a precaution against vital conditions which are missed in the field by "the average technician".
2. The "Single Combat with Death" syndrome where field people and ER's will pile tx and rx upon more of the same if things are not going well, creating a postive feedback situation.
3. Profit Motive.
4. Statistical skews. More pts die in EMS, and "if it worked it obviously wasn't a mistake" (??), so more EMS cases are dissected and thereby found wanting. Also, since EMS is the intake mode seeing pt's before they have undergone labs, xrays, etc etc, and without time to stabilize, not only will they generate more mortalities and extended morbidities, they will start unproductive treatments (misadventures) in hopes of doing good while waiting for imaging, labs, etc. They also act as a buffer to other departments by intiating these functions.
5. "ERROR": does it only include (willful) mistakes and misadventures, but (inadvertent) accidents as well?

And #6: field EMS and inner city hospital EMS are so poorly recompensed and inhospitable that they retain and attract and support suboptimal practitioners.

Heck yes protocols and outcomes need to be periodically revised, and hospitals need to devote much more resources to making ther emergency departments (#1 intake mode for visits of all kinds) effiicient and effective, as well as, or even "instead of", their high-profit centers like gastroenterology (think of elective cosmetic bariatric gastroplasties) and orthopaedics (knee replacements on demented 90 year olds, hip replacements on patients unable or unlikely to be able to follow through on sufficient rehab).

 

[Veneficus]

5. "ERROR": does it only include (willful) mistakes and misadventures, but (inadvertent) accidents as well?

It includes both active and latent errors.

 

[mycrofft]

"Latent"? I knew someone with a latent allergy once..

Thanks, got it. I bet they lumped misadventure with mistakes and accidents. Pt outcome is pt outcome.

 

[Veneficus]

Thanks, got it. I bet they lumped misadventure with mistakes and accidents. Pt outcome is pt outcome.

Active are all point of care issues. Latent are systemic failures.

 

[mgr22]

Does it seem like perhaps in order to reduce medical errors, save money, and not be negligent in the care of patients that perhaps more focused assessments and treatments need to be the future goal of US EMS?

Does it seem to you like not actively reveiwing and revising the common treatments in EMS perpetuates a culture of negligence and waste?

I think these two questions are particularly important. To improve, I believe we'd have to begin by quantifying how well or how badly we're doing those things. It seems that our industry is reluctant to measure quality of care. It's not just about call volume or response times. In my opinion, we need to look at how our prehospital impressions compare to prehospital treatment, and how prehospital care compares to hospital diagnoses.

 

[Veneficus]

It seems that our industry is reluctant to measure quality of care.

It has been my experience that people with something to show off are quick to do a study to quantify it.

Those reluctant to take an objective look probably already know they have something to hide.

It's not just about call volume or response times. In my opinion, we need to look at how our prehospital impressions compare to prehospital treatment, and how prehospital care compares to hospital diagnoses.

For certain.

I think since medicine changes so rapidly now, that all protocols need to be looked at very closely about every 5 years. But that is not only a shortcoming of EMS providers but of the totally ineffective medical direction of physicians.

The medical directors of hospital units are constantly scrutinizing and changing care standards and protocols. Why are EMS medical directors permitted to be so negligent?

 

[mgr22]

Why are EMS medical directors permitted to be so negligent?

I think part of the problem is that many EMS systems don't want medical direction and, therefore, look for docs who won't rock the boat. I see fault on both sides.

I believe that the best medical directors really do make their systems better. Medical direction and medical control don't have to be obstacles; they can be resources.

Good topic.

 

[ffemt8978]

I think part of the problem is that many EMS systems don't want medical direction and, therefore, look for docs who won't rock the boat. I see fault on both sides.

I believe that the best medical directors really do make their systems better. Medical direction and medical control don't have to be obstacles; they can be resources.

Good topic.

Here's a good example of that: http://www.emtlife.com/showthread.php?t=15603

 

[silver]

So I've done some work looking at medical errors in patient safety (specifically with in patient medication errors).

I think that this is an interesting topic that is never touched in EMS, but some of the language brought up so far might be interpreted incorrectly by some other readers:
Medical errors and adverse events are different. Some adverse events are not preventable, so regardless of what we do it will happen. While medical errors can cause preventable adverse events.

An example would be:
Adverse Event (not preventable) - After confirming the patient has no allergies (both medical record and by asking) and confirming no contraindication/increased risk for reaction, you give a medication and the patient has an allergic reaction. Oops...
Medical error (preventable) - You don't check for any allergies or ask and you give the medication (which lets say they are known to be allergic to in their medical record) and they have a reaction.

Edit: To clarify though, not all medical errors cause adverse events.

In regards to EMS I think that there are a lot of adverse events that are not preventable due to the nature of an emergency and lack of available information. This isn't to say that I medical errors don't happen. The general area where I think they probably occur the most is medication errors.

In my opinion, I wouldn't classify over treatment with IVs and oxygen as medical errors. I would consider those events as instances of substandard care.

 

[Veneficus]

Medical errors and adverse events are different. Some adverse events are not preventable, so regardless of what we do it will happen. While medical errors can cause preventable adverse events.

That is not the definition of the major studies regarding this topic nor of the institute of medicine. (IOM)

An example would be:
Adverse Event (not preventable) - After confirming the patient has no allergies (both medical record and by asking) and confirming no contraindication/increased risk for reaction, you give a medication and the patient has an allergic reaction. Oops...
Medical error (preventable) - You don't check for any allergies or ask and you give the medication (which lets say they are known to be allergic to in their medical record) and they have a reaction.

According to the definitions of the above, while not all adverse events are preventable in any system, all medical errors are adverse events.

In regards to EMS I think that there are a lot of adverse events that are not preventable due to the nature of an emergency and lack of available information. This isn't to say that I medical errors don't happen. The general area where I think they probably occur the most is medication errors..

unindicated administration of a medication as explained in the OP is considered an error.

In my opinion, I wouldn't classify over treatment with IVs and oxygen as medical errors. I would consider those events as instances of substandard care.

It is the classifications of the IOM, the leading authors, and the JCAHO that are the authority as far as medical professionals are concerned.

 

[mycrofft]

Error versus willful negligence or malpractice...JIC

I KNOW the County EMS standard says no to JIC (just in case) IV starts, but I do them anyway. The pt says he has a slipped disk by hx and c/o, but I start him on O2 JIC. The pt slipped and sprained an ankle on a curb, so I spineboard 'em...JIC.
If (or as long as )these do not cause a harmful sequelum, they go unreported; remember though, "The mechanism was benign, but the outcome malign" and vice versa, meaning "Sometimes you get lucky, then, SNAP".:wacko:

 

[silver]

That is not the definition of the major studies regarding this topic nor of the institute of medicine. (IOM)

I am not giving a definition. I'm noting a difference. I will get out my binder of articles to prove the difference:
1991 Harvard Medical Practice Study; the one you were referencing earlier by Brennan et al denotes a clear separation of adverse events and errors. "Most adverse events are preventable, however, particularly those due to error or negligence. Our findings confirm the observations of others - that errors in medical practice are common."

1995 Incidence of adverse Drug Events... - Bates et al article "medication errors - defined as any error in the process of ordering, dispensing, or administering a drug."

These studies and others (mostly by the godfathers of patient safety like leape, brennan, and bates etc.) led to the definition set by IOM in to err is human in 1999
From the report - "Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."

"Not all errors result in harm. Errors that do result in injury are sometimes called preventable adverse events. An adverse event is an injury resulting from a medical intervention, or in other words, it is not due to the underlying condition of the patient. While all adverse events result from medical management, not all are preventable (i.e., not all are attributable to errors)."

This report is also over 11 years old so much has changed, but that is generally the definition given still.

According to the definitions of the above, while not all adverse events are preventable in any system, all medical errors are adverse events.

The Medical Practice Study also defines an adverse event as an injury due to medical treatment. So an injury can be caused by a medical error.

unindicated administration of a medication as explained in the OP is considered an error.

I can understand your point, but I have yet to read an article/book that considers O2 PRN, as a standing order, an error. It would be interesting maybe to start research in that for EMS...My view is it would be like saying the surgeon who is old school and does an "archaic" method of surgery rather than a new one is in error if there are no outcome differences. (I don't actually know if there is an outcome difference for O2)

It is the classifications of the IOM, the leading authors, and the JCAHO that are the authority as far as medical professionals are concerned.

I haven't seen that in my literature searches over the past two years. Again its a fine line of interpretation, but all the research I've read does not include that as an error.

In reality, the only classifications that anyone cares about are the never events, reportable errors/events and indicators + triggers that are required reporting to people like the health dept, state, CMS + other parts of DHHS, and the joint commission (no longer JCAHO).

 

[Veneficus]

I am not giving a definition. I'm noting a difference. I will get out my binder of articles to prove the difference:
1991 Harvard Medical Practice Study; the one you were referencing earlier by Brennan et al denotes a clear separation of adverse events and errors. "Most adverse events are preventable, however, particularly those due to error or negligence. Our findings confirm the observations of others - that errors in medical practice are common."

1995 Incidence of adverse Drug Events... - Bates et al article "medication errors - defined as any error in the process of ordering, dispensing, or administering a drug."

These studies and others (mostly by the godfathers of patient safety like leape, brennan, and bates etc.) led to the definition set by IOM in to err is human in 1999
From the report - "Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."

"Not all errors result in harm. Errors that do result in injury are sometimes called preventable adverse events. An adverse event is an injury resulting from a medical intervention, or in other words, it is not due to the underlying condition of the patient. While all adverse events result from medical management, not all are preventable (i.e., not all are attributable to errors)."

I don't see how this differs from what I was trying to say. Though I admit i was trying to not type out every detail so i may be assuming understanding of what i meant.

This report is also over 11 years old so much has changed, but that is generally the definition given still.

What has changed?

The Medical Practice Study also defines an adverse event as an injury due to medical treatment. So an injury can be caused by a medical error.

that was my point.

I can understand your point, but I have yet to read an article/book that considers O2 PRN, as a standing order, an error.

o2 as needed, no, high flow o2 when not indicated is an error in just about every medical text I own and a few basic science texts like physio as well.

It would be interesting maybe to start research in that for EMS...My view is it would be like saying the surgeon who is old school and does an "archaic" method of surgery rather than a new one is in error if there are no outcome differences. (I don't actually know if there is an outcome difference for O2)

but the outcome has to be measured long term, not just to the ED.

I haven't seen that in my literature searches over the past two years. Again its a fine line of interpretation, but all the research I've read does not include that as an error.

Sabiston Textbook of Surgery, chapter 11.

In reality, the only classifications that anyone cares about are the never events, reportable errors/events and indicators + triggers that are required reporting to people like the health dept, state, CMS + other parts of DHHS, and the joint commission (no longer JCAHO).

My experience is different.

 

[mycrofft]

Accident versus error versus negligence/caprice, and/versus malice

ACCIDENT: intent to help but unintentionally harmed and despite due diligence. Dropped something, or the patient rolled at the wrong time despite precautions.

ERROR: Intent to help, but without malice; due to ignorance, for whatever reason, of some factor(s). The action caused or exacerbated the outcome. Didn't get a good grip, or the pt was not immobilized properly.

NEGLIGENCE/CAPRICE: Due diligence was not observed despite knowledge, and affected the outcome. "Caprice" is a carelessness of action, while "Negligence" is a carelessness of inaction. "We never do things that way", improvising when that is not the last ditch measure available.

MALICE: Converts any event into a tort, a battery. Also a contributing factor to all the above if it influences due diligence, such as but not limited to socio-cultural stereotyping, hatred for spouse batterers, etc. Hence "the race card".

Like playing with matches, until the house catches fire, these go on forever without being recorded. That can mean that the diligence is unrealistic (e.g., "spineboard every single pt"), or some other factor is preventing bad outcome, including dumb luck.

 

[firetender]

A lot to swallow!

Just speaking as a firetender, Vene, you always bring compelling thoughts to the table but sometimes send them in an avalanche of words! Sometimes as I go, I need to do a lot of digging to get to where I can build on or respond to your thoughts. Here's what I have to do with this one:

Brennan et al. defined adverse events as and injury caused by medical management that prolonged hospitalization, produced disability at time of discharge, or both.

Diagnostic, noninvasive theraputic, and emergency department events produced most of the negligent complications.

treatments that are not needed are erroneous.

we haven't even considerd errors in the technique issues for things like ETT.

How about IV starts? How many are really medically indicated?

This obviously gives way to significant overtreatment. So what right?

How much of that is attributable to prehospital care? I

Medical errors are the 8th leading cause of death in the US.

***remember this does not take into account the numbers from EMS*** Which would make these numbers higher.

(snip, snip, hack, chainsaw!)

...and then you ask no less than 8 separate questions, each of which could deserve its own thread. I'm not criticizing; I wouldn't take the time unless I were intrigued, but what I'm left with is that you missed the most important element of the whole discussion:

What would be the morbidity and mortality if NO INTERVENTION WERE ATTEMPTED?

So, in this respect, it feels like apples and oranges because emergency on-the-street or in-the-home intervention is NOT about long term recovery but intervention enough to get the patients to the next, higher level of diagnosis and care.

Part of that involves, for example, initiating medications in the field that need to be compensated for in the ER. Emergency intervention, field or ER often involves quite a bit of juggling until something definitive is figured out and THEN the patient gets shifted to the next level of care.

The field is all about doing your best under the circumstances you are exposed to. It does not provide the luxury of long-term thinking because it only involves a very limited view of the Big Picture. THAT comes later after the use of all these Computerized Diagnostics.

Of the Field, the ER and the Floor, the Field needs to be treated as having the least complete overview of what sound medical care should be for the patient. Since the alternative (NON-INTERVENTION) would even be MORE likely to hasten death and prolong recovery, it should be viewed separately.

So now I guess my question is what's your question?

 

[18G]

This months issue of JEMS had in the research column two studies on Paramedic efficiency in performing drug calculations. The results were absolutely horrible and embarrassing.

 

[Veneficus]

So now I guess my question is what's your question?

Some of those questions are rhetorical. The point was to get people thinking, not to simply answer questions.

But I would like to address What you mentioned about care in the street and the next higher level.

One of my observations in both intensive care and surgery is that the prior events cannot be seen as seperate. You cannot hope to do something to a really sick person, then do something else to them, then initiate a third set of treatments and think that it is not the same as a mad scientist mixing chemicals. (figuratively, sometimes literally)

As an example, i will use atropine in bradycardia.

You push the med, the patient meets all protocol criteria for the sake of argument, and you increase the heartrate.

Heart rate increased. Blood pressure numerically better. Patient clinically improves. Score!!!

But what the EMS providers didn't think about or see, is that making that patient better in the short course may have killed them or increased the level of morbitiy.

Figure the increase in HR and increase in BP cause the heart to work harder with more metabolic demands on the cells. Which couldn't meet the basal metabolic demand which is why EMS was called. This temporary relief causes hibernating cells to take a step to irreversable damage.

Coagulative necrosis, which is how a majority of cells finally die takes about 4 days.

Which means that the treatment provided on the street was the death blow that played out in the ICU. Nothing that could be done in either open surgery or endovascularly can save those cells, much less bring them back. Nothing that is done post op in the ICU can bring those cells back.

Ever notice when somebody gets hurt and it shows up in the news, it takes days for doctors to say what the prognosis might be?

It is not becase they are always running a battery of tests, it is because they are waiting to see if the person survives the initial insult. It's about day 4 they can say for sure active cell death from that initial insult has stopped.

I would agree in the days of hoping to simply deliver a dying patient to the ED alive, any level of alive was a win. But today EMS is treating so much more than the near death. They are actually tasked with not letting it get that far.

In the field, for a variety of reasons, some changable, some not, there is a vast quantity of unknowns. Even in the best medicine areas there are not always known ways to detect cell injury prior to cell death.

I don't think it is fair to fault EMS for the error of overtreatment. But I think it is important to admit to it so that we can start talking about how to make things better for the patients whose pathology doesn't reset at each artificial seperation we have imposed.

Common pathology changes over time. Knowledge of pathology and treatment changes very rapidly. EMS is not keeping pace.

For once not because of education But in the attempt to perfect the administration and technique of care that is no longer applicable in many cases and outright harmful in others, it is like perfecting the medicine that is no longer applicable instead of focusing on newer and perhaps better treatments.

"Scene safe!" if you don't know what danger looks like, how do you know if it is present?

"Do no harm." If you don't know what helps and what harms, how do you achieve that?

 

[firetender]

But I would like to address What you mentioned about care in the street and the next higher level.

Still, how does that relate to the fact that if NOTHING were done, there'd be NOTHING to work with?

 

[Veneficus]

Still, how does that relate to the fact that if NOTHING were done, there'd be NOTHING to work with?

see the new thread

But basically, I am not suggesting do nothing. The trick is not to overdo.

Life is a balance. You can be off by tilting either part of the scale too much in every aspect of human existance.