Epinephrine Error

[boingo]

Our 1:10,000 epi comes in a bristojet, the 1:1,000 in a small glass ampule. I would guess theirs is packaged the same way. I'm guessing they were suspecting anaphylaxis and decided to give epi IV however used the 1:1,000 instead of the 1:10,000. The dose is the same however the concentration is much different. As far as what was assessed or not, hard to say. Did they find someone with an unmanageable airway? Were two medics dealing with that while the third established a line, drew up meds etc? I give them credit for reporting their mistake. I don't think this should be an issue of discipline at all. Addressing the mistake from a clinical standpoint makes sense. Not reporting an error is a much different story.

 

[thowle]

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?

Computers are good for a lot of things. In an emergency situation where time counts, it may not always be 100% time effective to use the computer.. however, I suppose that we could always develop a system where there would be a touchscreen LCD mounted near the primary shelf in the back, somewhere around the CPR bench, and have it with large display and touchscreen buttons that would allow entry of information of a patient to aid with the administration of treatment/medication; however -- it still doesn't take the place of knowledge and double-checking each other by verbal response.

There is always room for error; one wrong push of a button, or not enough information and then you have the computer confirming something that isn't correct.

You could always have it operate as an MDT where you are directly communicating with the medical director or ED; possible even with remove broadcast using a camera -- but still, the time delay may become a factor at times.

Speech-to-text? Not always accurate -- how often do you call the Google 411 and it gets what you request correct the first time? Try it now with the fan, siren, and other noises from the back of the rig? Even if you're wearing a remote/wireless neck/mic harness. It would for sure add to the fustration levels associated with the job already.

Interface with LifePak monitor and PulseOx? Sure, we're getting somewhere now; but then we can only get some information from the patient.

Again, computers are good and great for a lot of things; but chances are this would not really "help", and only add fustration to the situation... we just need a comprehensive method for checks-and-balances to be taken place during treatment; other than that... mistakes happen; learn from it; study what you did, why you did it, what you could have done different/better, and apply it next time -- don't get discouraged (even though sometimes for some people we might think they need to ).

 

[46Young]

All meds, and I do mean ALL meds should be treated as if they have the potential to kill, and be respected as such.

On my second shift as a newly released ALS provider, my senior medic partner and I were treating a stat ep. I couldn't get a line for anything, and he pulled out the valium. He asked me what the dose is, and I told him correctly (5mg). He then handed me the syringe and told me to push it IM. It didn't sound right, though I couldn't remember exactly why. I figured that, as an FTO, he knew the right thing to do, so I did it. Valium only goes IV here. Ativan goes IM. The Sz didn't break. The pt turned out okay, thankfully, and we both received remediation and 6 months probation (that was 18 months total for me). The next med error would result in termination, no questions asked, and rightfully so. It unfortunately takes actually making a mistake and suffering the consequences to straighten you out.

Partners will look at me and ask why I'm calling out the med, conc, doseage, exp, intended route, and handing them the syringe with the needle still in the vial. This is over four years later after that error that I'm still doing this. I occasionally hand a partner the wrong med to draw up, if time is not of the essence, to see if they catch it, to not become complacent.

I advise everyone to watch your partner, and question them if needed, even if they outrank you, such as a "lead" medic, or an Lt/Capt. Some agencies, such as mine, regard an EMT-I and an EMT-P as one and the same (puzzles me). The courts don't, however. If your lead is of a lower cert level as such, it's your neck (job, successful lawsuit, P-card) on the line if things go wrong.

I've imposed my will on lazy/complacent med officers for pt care issues when needed. I'm lucky that the ones in my station are not that way. Detail officers and OT personnel can vary.

 

[usalsfyre]

a dose is a dose is a dose......

If I'm not mistaken a milligram of epi is a milligram of epi no matter whether it's in 1ml, 10mls or 1000mls. Getting hung up on what concentration is given IV seems a little ridiculous. Didn't anyone used to carry the 30mgs in 30ml multidose vials for "extended transports".

The real issue is why did no one do a complete assessment (including V/S)initially. And what "airway management" was done at the five minute mark?

 

[rescue99]

Our 1:10,000 epi comes in a bristojet, the 1:1,000 in a small glass ampule. I would guess theirs is packaged the same way. I'm guessing they were suspecting anaphylaxis and decided to give epi IV however used the 1:1,000 instead of the 1:10,000. The dose is the same however the concentration is much different. As far as what was assessed or not, hard to say. Did they find someone with an unmanageable airway? Were two medics dealing with that while the third established a line, drew up meds etc? I give them credit for reporting their mistake. I don't think this should be an issue of discipline at all. Addressing the mistake from a clinical standpoint makes sense. Not reporting an error is a much different story.

Wow..not an disciplinary issue..really? There's a big issue with giving the wrong (any) concentration of epi to a victim of an unassessed problem. I'm not sure...was this an allergic reaction or orolingual angioedema for some other reason? Some neuro patients will present with a swollen tongue for example. What was the likely cause of the edema?

There were enough people there to have done what they needed yet, there simply wasn't enough information gathered. No differentials were even mentioned from what little I gathered in the article.

 

[VentMedic]

Wow..not an disciplinary issue..really? There's a big issue with giving the wrong (any) concentration of epi to a victim of an unassessed problem. I'm not sure...was this an allergic reaction or orolingual angioedema for some other reason? Some neuro patients will present with a swollen tongue for example. What was the likely cause of the edema?

Angioedema? Ace Inhibitors for one or reactions with prescription and street meds like meth.

If the person reports their own med error there should not be a severe punishment. Med errors are encouraged to be reported as quickly as possible so action can be taken to prevent it from becoming deadly. As I stated before, med errors occur in the hospital. Those that recognize their mistakes quickly rarely suffer harsh consequences. It is those that attempt to cover up their mistakes or practice "what happens in the truck stays in the truck" mentality are the ones who need to face a disciplinary hearing.

Does any state require "Medical Errors" as part of their CEs and certification renewal?

 

[rescue99]

Angioedema? Ace Inhibitors for one or reactions with prescription and street meds like meth.

If the person reports their own med error there should not be a severe punishment. Med errors are encouraged to be reported as quickly as possible so action can be taken to prevent it from becoming deadly. As I stated before, med errors occur in the hospital. Those that recognize their mistakes quickly rarely suffer harsh consequences. It is those that attempt to cover up their mistakes or practice "what happens in the truck stays in the truck" mentality are the ones who need to face a disciplinary hearing.

Does any state require "Medical Errors" as part of their CEs and certification renewal?

The point was...something is warrented.

 

[usalsfyre]

If the error was self reported, and there wasn't a history of med error, remediation and a record of the error for future tracking is probably all that's waranted. Punishing medical errors encourages hiding medical errors, this is an area where EMS is FAR behind the times.

 

[VentMedic]

The point was...something is warrented.

Med errors should not be punished if that individual made their mistake known. There are probably many other things that could get a reprimand on this call but it shouldn't be for the epinephrine.

Of course, there are a handful of errors with medications that are blatant negligence like failing to check the patiency of an IV and failing to notice an infiltrate. Assuming responsibility for a med you know little to nothing about and that includes the med pump it might be attached to is another critical error but that pertains more to judgment than the med.

 

[el Murpharino]

If I'm not mistaken a milligram of epi is a milligram of epi no matter whether it's in 1ml, 10mls or 1000mls.

1 mg of epi 1:1,000 is NOT the same as 1 mg epi 1:10,000...

 

[usalsfyre]

1 mg of epi 1:1,000 is NOT the same as 1 mg epi 1:10,000...

What (other than 9mls of solution) is the difference?

 

[Crepitus]

What (other than 9mls of solution) is the difference?

It often used to be that the 1:1000 in the small glass ampules was an oil based product designed for SC/IM use. We did carry the 30 mg vials of 1:1000 in the days of high does epi. They were the conventional base for mixing different doses.

I have had a physician order 1:1000 IV - an order we were able to wiggle out of and not give. I've given the 1:10,000 IV for anaphalaxis, though the service I worked for at the time did not endorse that route for that condition.

But overall I guess I was under the same impression as you. I thought 1 mg of epi is 1 mg of epi (other than the oil based forumulation). If you know how to get the right concentration in the right place can't you make just about anything work in a pinch?

 

[Shishkabob]

1 mg of a drug is 1 mg of a drug.

If I put a tablespoon of salt in a glass, and a tablespoon of salt in a pool, there's still a tablespoon of salt. The only difference is the concentration.



Unless I'm totally missing something?

 

[Ridryder911]

1 mg of a drug is 1 mg of a drug.

If I put a tablespoon of salt in a glass, and a tablespoon of salt in a pool, there's still a tablespoon of salt. The only difference is the concentration.



Unless I'm totally missing something?

True, but many of those in EMS do not understand dilution principles as described by diluting Epi 1:10,000 for 1:1,000. Look up the proper dilution procedures and one will find that it would be a major medication error.

R/r 911

 

[medic_texas]

So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations?

1:10,000
1:1,000

Also, the vial isn't "oil based" and can be given IV - how do you think we mix epi- drips? 1 vial + 250ml of NS or D5W (this is in another thread as well).

I'm not even going to explain this but I think everyone who posted in this thread needs to read about dilution, concentration, and the differences between the two epinephrine meds that are on almost every EMS unit.

<speechless>

 

[DV_EMT]

Epi is Epi... but concentrations differ.

as for the oil based statement.... way way off there. Just as medic_tx stated... epi bags are diluted. its not oil otherwise the epi would just sit on top or bottom of the bag...

as for the concentration question.... one is designed for pediatric pts. It goes the same for atropine I believe (if my memory isn't faulty). I think its a good idea to have the two strengths because it "CAN" reduce medication dosing error. if you give an adult a Ped size.. theres no problem. but if you go the other way.... BIG PROBLEM. I think keeping people to the "big size - big person; Small Size - small person" mentality... there'd be a lot lower medication error....

and put them away from each other. designate a PED area vs. ADULT area... that way you know the right package is in the right spot. I actually checked another pharmacist the other day by intentionally putting a different drug to be checked... same route and size... and they both started with the letters "DO..." though they were very different drugs they were the same size vials and roughly same concentration (and same box for that matter)

The pharmacist did their job, caught the error, and informed me. I then showed the pharmacist that there could be potential med errors like this in the future because the drugs were located right next to each other and someone could easilly be in a hurry and grab the wrong drug.

It just goes to show... stock rotation can be very very helpful.... esp in the case of an emergency

 

[Shishkabob]

So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations?

1:10,000
1:1,000

I'm not even going to explain this but I think everyone who posted in this thread needs to read about dilution, concentration, and the differences between the two epinephrine meds that are on almost every EMS unit.

<speechless>

Errr???





In both a 1:10 and 1:1 solution, there is 1mg of Epi, AT ALL TIMES. The only difference between the 2 is how concentrated it is. 1:1 has 1mg in 1ml of fluid, while 1:10 has 1mg in 10ml, or .1mg in 1ml of fluid.

If you give 1ml of each, then yes, there is less Epi in the 1:10, but if you give the whole thing, there's still 1mg in both.




Again, a tablespoon of salt in a pool and a tablespoon of salt in a glass... there's still a tablespoon of salt.

 

[medic_texas]

Errr???





In both a 1:10 and 1:1 solution, there is 1mg of Epi, AT ALL TIMES. The only difference between the 2 is how concentrated it is. 1:1 has 1mg in 1ml of fluid, while 1:10 has 1mg in 10ml, or .1mg in 1ml of fluid.

If you give 1ml of each, then yes, there is less Epi in the 1:10, but if you give the whole thing, there's still 1mg in both.




Again, a tablespoon of salt in a pool and a tablespoon of salt in a glass... there's still a tablespoon of salt.

Where did I say there was a difference in the milligram? I want people to think why there is 2 different concentration ratios of Epi.

Why do we have 2 different concentrations?

I'm glad you cleared up the concentration ratio for everyone, but I'm already aware. No use trying to give me flak by quoting my post. I think you misunderstood my post and were pretty quick to try and "prove me wrong".

Obviously there is a huge issue on this because 3 medics on a call can't figure out the right medication, the right dose, the right route, the right patient, and the right time. I find that some of the people that post here are just as scary.

 

[Shishkabob]

I read

"So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations? "


And extrapolated that you were saying they were not the same. If that's not the case, I'm sorry. If that is the case, that's why I wrote the post.

 

[medic_texas]

I read

"So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations? "


And extrapolated that you were saying they were not the same. If that's not the case, I'm sorry. If that is the case, that's why I wrote the post.

Ok, glad we cleared that up.

I was just annoyed at all of the posts that I read through and some of the inaccurate information that was given. You should have read my original post before I edited it. lol