D'oh!

homerMedication safety is a topic I am focusing on these days. How to prevent errors and keep our patients safe.

Since I am a clinical coordinator responsible for overseeing medication safety, and as someone writing about it, and as a paramedic responsible for my own patients, I need to live up to the standard.

It is with regret that I must describe the following;

We have three ambulances at the base I report to each morning I work. Only one is on-line. The second and third are available for call-in crews. We have four regular medics with one set of medical gear. Each medic is assigned to an ambulance, two of the medics share the same ambulance.

When I come in at quarter to six, I move the ambulances around so my ambulance is in one of the front positions in bay. I then move the medic gear from the night ambulance into mine.

Here is what I move each morning;

Lifepack 12 monitor
Medic House bag
Pedi-bag
Spare meds kits
2 controlled substances kits
Crick kit
Digital camera
Toughbook computer
Power stretcher

I also have to check my ambulance out for supplies, 02, linens, boards, etc.

No big deal. Been doing it for years.

Other morning I come in, move the gear, check the ambulance. All seems well.

Couple hours later, we get a call for back pain. Take off, arrive at the scene. Go to pull the stretcher, something seems not right.

“Where’s the monitor?!”

D’oh!

Not funny at the time.

Fortunately, the patient’s problem was pretty straight forward muscular. Nevertheless, I asked the patient and their family member if they minded if we took a two minute detour to swing by our headquarters to pick up a piece of equipment we would need to stay in service at the hospital. They were cool about it.
We picked up the monitor (left in the night ambulance) and I breathed some relief that the scenario was not different. I don’t want to think about what might have happened.

So how do I prevent this from happening again, once the memory of the near disaster starts to fade? I need to improve my personal system. A checklist perhaps. Long ago I went from a checklist to visual checking. Maybe I need to return to that system.

The other thing that I could do more stringently, which I do periodically, is always glance in the back prior to leaving on any call.

That has saved me before. I instituted that change after this famous call:

The Stretcher

1 Comment

  • As much as I hate check lists they do help me to not gloss over things. I’ve left our bag with all the cervical spine precaution equipment on the scene of a call once. D’oh indeed. I didn’t realize it until the next call when I needed to c-spine a patient. Fortunately the ambulance crew had what we needed.

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