Epinephrine Error

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VentMedic

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This is not to bash the Paramedics involved but to point out how easily errors can be made. Learn from the mistakes of others so you do not make headlines.


3 Acushnet paramedics cited in flawed emergency call

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090916/NEWS/909160333/-1/NEWSMAP


As the paramedics were working on the patient, Mentzer and Gonsalves noticed the patient's tongue was swelling, a symptom that indicated to Mentzer an anaphylactic reaction, and Gonsalves administered epinephrine, or adrenalin, through the patient's intravenous line, according to the report.

That, according to the report, was a mistake: The concentration of epinephrine Gonsalves gave the patient should have been administered through an injection under the skin, a less direct route, rather than intravenously.
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Gonsalves, who admitted to giving the medication incorrectly, also told an investigator "she may not have had enough information to have even gone down that treatment pathway because she lacked a full set of vital signs or a clear history of the present illness," the report stated.

Neither Gonsalves nor Farland conducted a patient assessment, instead relying on information from Mentzer, the first paramedic at the scene, according to the report.

Additionally, there were delays in initiating care for the patient, according to the report: Airway management was not started until five minutes after Mentzer arrived at the scene, and blood pressure was first taken 10 minutes after the paramedics got to the emergency scene.

"In this case, EMT-Paramedic Farland, Gonsalves and Mentzer all failed to properly assess a patient, but rather had tunnel vision on the visual symptom of the swollen tongue," the report stated.
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Hmm not good.

Now how can we systematically reduce or eliminate this error from happening again?
 
silver said:
Hmm not good.

Now how can we systematically reduce or eliminate this error from happening again?
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By doing a proper assesment on every patient, not getting lazy, and paying attention to what you're doing.
 
Proper assessment and know the five rights of drug administration.

Right drug
Right dose
Right route
Right time
Right patient
 
We need to build in system controls that make this mistake harder to make again. Does that mean we supply the concentrations for IV use seperately from IM? Make it impossible for needles used for IM injections to be used for IV (I know, they are the same)? Modify the ePCR to operate like a CPOE (computerized physician order entry) in hospitals, rechecking all dosages, routes, etc?

How can we build safety nets into our systems, so there are checks on human error?
 
On one hand, she should be commended on admitting her mistake freely. It doesn't excuse the rest of the stupidity, but it's better than covering it up.
 
Even though I titled this thread "Epinephrine Error", I find more fault with the assessment done on scene by the 3 Paramedics than I do the Epinephrine administration.

Medication errors are made fairly often and the system in place should not be there to punish those committing them if that person catches the error themselves.

There were 3 Paramedics on this scene who should have established some priorities and got some type of assessment done. If someone had assessed the airway, they may have been able to establish some type of control over it to buy time to do a proper assessment. Someone also had time to establish the IV through which the medication was given.

Mentzer immediately recognized the patient was seriously ill and called the EMS dispatcher for additional assistance; Farland arrived as the patient was being loaded into the ambulance, and Gonsalves got there soon after, according to the report.
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And, why was the last Paramedic to join the scene and who probably knew the least about the patient giving the meds?

I am not bashing these Paramedics. This is actually a very common response in places, like Collier county (or Florida and California), where an ALS engine may respond first with 2 - 4 Paramedics, a Fire Rescue Truck may be behind it with 2 more Paramedics and then another 2 Paramedics in the transporting ambulance take the patient to the hospital.
 
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emt.dan said:
We need to build in system controls that make this mistake harder to make again. Does that mean we supply the concentrations for IV use seperately from IM? Make it impossible for needles used for IM injections to be used for IV (I know, they are the same)? Modify the ePCR to operate like a CPOE (computerized physician order entry) in hospitals, rechecking all dosages, routes, etc?

How can we build safety nets into our systems, so there are checks on human error?
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A mechanical control might work well in situations like this. Anyone remember the pediatric heparin dose issue from a few years ago?
 
Yep.
Although heparin overdoses are a rare occurrence, the same error killed three infants and harmed three others late last year at Methodist Hospital in Indianapolis. This prompted a warning from Baxter Healthcare and the FDA about the potential for medication mix-ups between the two dosage vials, which both had blue labels.
...
The company introduced new packaging in October to address the problem, King said. The labels now have separate color combinations for the two dose vials, a large red alert symbol, 20% larger type fonts, and a tear-off "turtleneck."
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http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/7469


If memory serves me correctly, the same issue occured with people mixing up an OTC eye drop with an OTC ear drop solution.
 
Due to the large number of medications used in a hospital the list of errors that have been made and those situations which could allow for errors to be made are many.

This is why we now have standardized abbreviations and have eliminated some of those that did create errors in the past. As well, drug manufacturers are being more cautious with their packaging. The dispensing machines are also more sophisticated with bar scanners which identify the medications the patient is listed with to the actual medication.

But, EMS does not carry 300 different medications nor does one Paramedic pass over 100 -300 medications per 8 or 12 hour shift with multiple patients at one time in their responsibility.
 
Regardless, if a manufactured solution can be found to prevent similar errors, it's worth exploring regardless of if it's for the provider with 1000 medications to administer or just 2. Manufactured solutions, or the lack there of, also doesn't dismiss blame for the blantant stupidity shown on this specific EMS call.

Should hospitals be denied manufactured safe sharps because their environment is much more controlled and stable than EMS?
 
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What do your 1:1000 Epinephrine vials look like and what do the containers carrying 1:10,000 look like?
 
I've not dealt with epi, but I've dealt with heparin. Halfway through my thesis, my labs supply of heparin changed from (if I recall correctly) 1000 unit vials to 5000 unit vials. Now since it was diluted into phosphate buffer solution anyways, it was a simple calculation to change the volumes used. However the difference between the two concentrations was the color in a little box that the concentration was in and it wasn't very noticeable.
 
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JPINFV said:
Regardless, if a manufactured solution can be found to prevent similar errors, it's worth exploring regardless of if it's for the provider with 1000 medications to administer or just 2. Manufactured solutions, or the lack there of, also doesn't dismiss blame for the blantant stupidity shown on this specific EMS call.
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Manufacturers are responding to the errors made due to packaging. Hospitals are continuously updating, educating and training their employees. What more do you want? The hospital staff know mistakes can easily be made. We even now are only allowing one RN/RRT in the med room at a time to get their meds so they are not distracted.

I again said I was not bashing these Paramedics except for someone not taking responsibility to see things where done in an orderly manner so the correct procedures and medication could be done.


JPINFV said:
Should hospitals be denied manufactured safe sharps because their environment is much more controlled and stable than EMS?
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I have no clue what you mean by this. I already stated hospital staff have made many med errors. We care for large numbers of patients with large numbers of medications given to each patient. The staff, the hospitals and the drug manufacturers are doing whatever they can to make the hospital a safer environment. Why shouldn't hospitals have safeguards in place? Why shouldn't EMS have safeguards in place to ensure all present have similiar information especially the one pushing the medications.
 
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JPINFV said:
I've not dealt with epi, but I've dealt with heparin. Halfway through my thesis, my labs supply of heparin changed from (if I recall correctly) 1000 unit vials to 5000 unit vials. Now since it was diluted into phosphate buffer solution anyways, it was a simple calculation to change the volumes used. However the difference between the two concentrations was the color in a little box that the concentration was in and it wasn't very noticeable.
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Very, very, very few EMS trucks will carry heparin. Only Flight, Specialty and some CCTs might carry it. And again, the heparin manufacturers have agreed to change their packaging and many hospitals have changed their storage situation.

The med error here was with Epinephrine.

Usually there is a noticable difference in packaging of the 1:1000 and the 1:10,000.

Correct route. Correct dose.
 
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VentMedic said:
Manufacturers are responding to the errors made due to packaging. Hospitals are continuously updating, educating and training their employees. What more do you want? The hospital staff know mistakes can easily be made. We even now are only allowing one RN/RRT in the med room at a time to get their meds so they are not distracted.

I have no clue what you mean by this. I already stated hospitals have made many med errors. We care for large numbers of patients with large numbers of medications given to each patient. The staff, the hospitals and the drug manufacturers are doing whatever they can to make the hospital a safer environment. Why shouldn't hospitals have safeguards in place? Why shouldn't EMS have safeguards in place to ensure all present have similiar information especially the one pushing the medications.
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Nothing more can be asked except to produce manufactured solutions where possible regardless of who is ultimately at fault in the end. Maybe I misread your earlier posts, but it seemed like you were saying that EMS doesn't need manufactured solutions (like improved labeling) because of the comparatively low amount of pharmaceuticals used (both in variety and total number) compared to the hospital. My view on this is that where manufactured solutions can be developed and implemented is a separate issue from the specifics of any case. If a manufactured solution could be produced that would prevent a 'right route' error then it should be implicated regardless of if providers are failing to conduct a proper assessment.
 
VentMedic said:
Very, very, very few EMS trucks will carry heparin. Only Flight, Specialty and some CCTs might carry it. And again, the heparin manufacturers have agreed to change their packaging and many hospitals have changed their storage situation.
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I never claimed that they did, nor that I was using it in an EMS function. The heparin was ordered, delivered, and used earlier in this year. Of course how I used it (including storage) would never fly with human administration anyways, but that's a difference between research and medical care.

As far as epinephrine, I'll freely admit that the only epinephrine that I've ever had the chance to use (which I never had the opportunity to use) came in a device resembling more of a pen than anything else.
 
JPINFV said:
but it seemed like you were saying that EMS doesn't need manufactured solutions (like improved labeling) because of the comparatively low amount of pharmaceuticals used (both in variety and total number) compared to the hospital.
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News flash! Most of the meds used on EMS trucks are the same ones used in hospitals. In fact, some hospitals are set up to restock the ambulance with meds.

3 Paramedics on scene with one patient. In many places there may be 10 Paramedics with one patient. If someone doesn't have some control or idea of who is doing what, it is chaos and errors occur.

Do you also not see where it can be easy for an RN who may be responsible for handing out 300 medications in one shift to make an error? Therefore, it has become a major issue with safeguards being placed.

I just find it unbelievable that some in EMS get offended when something like medication errors, assessment and scene organization are discussed. This thread probably would have more successful if I had not asked for the crew members not to be blatantly bashed. However, some are more comfortable with that then they are patient care and safety concerns.
 
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silver said:
Hmm not good.

Now how can we systematically reduce or eliminate this error from happening again?
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Education continuing education,staying alert and not getting lazy or taking things for granted. While the chances for a medication error are always going to be there we all need to be aware of what we are doing. In the case where someone else draws up or takes a med out of the bag for you take a second to make sure you are getting what you need. None of us are perfect and most do not mind if you look at the package a med came out of or check the dosage before you administer it. As for the evaluation I was not there so I don't know what happened but we all need to take time to insure that we take care of the basics first.
 
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