When I went to nursing school, I found two of the biggest differences between nursing and paramedic education were the nursing emphasis on medication safety and asepsis. While I do not recall being taught about either in paramedic school, since that was almost twenty years ago, my recollection may be poor. We no doubt touched on both subjects, but likely we touched upon them only in passing. I can say that in my two decades of field medicine, both in my own practice and in observation of my peers, medication safety and aspepsis are not often high on the priority list.
In 1999 Institute of Medicine Report issued their landmark report: Too Err is Human. They estimated that between 44,000 and 98,000 people die in hospitals each year as a result of preventable medical errors. That’s more deaths than motor-vehicle wrecks, breast cancer, and AIDS combined. They reported that serious errors occurred most often in emergency departments, operating rooms and intensive care units. The cost of these errors was estimated to be between $17 billion and $29 billion per year in additional care, lost income and household productivity, and disability.
Listen to this key statement: “The majority of medical errors do not result from individual recklessness.” Faulty systems are usually to blame. Now this doesn’t mean that people should be excused from their responsibility or not be held accountable for their errors. What is does mean is that when errors are made, we should always look at how they were made and how they could be prevented. If a person can make an error, other people can likely make the same error, so we need to look at the system and figure out how to make it harder to make that error.
A great example of this, which I wrote about in Medication Errors – Epinephrine – is stocking high dose epinephrine. If medics have to draw up high-dose epi either in a syringe to give IM or to be diluted to give IV, there exits the opportunity for a patient to get a lethal dose. Its not going to happen every time, but there have been a number of fatalities due to just this accident waiting to happen. So, to prevent lethal errors, you change the system – you provide epi-pens instead of high-dose vials. It’s more expensive, but it can spare lives.
The aviation industry has long been a leader in safety initiatives. Their Aviation Safety and Reporting System (ASRS) documents adverse events and near misses. Anytime someone even imagines how an accident could occur, it is analyzed and the system made safer.
Hospitals are required to report adverse events. Serious Reportable Events (SREs) developed by the National Quality Forum, include 28 events that must be reported, including death or serious disability from medication error.
I’ve recited to you the stats on hospital errors, but when it comes to EMS – a far more uncontrolled environment, there is virtually no error reporting. EMS treats 30 million patients a year. 10 million patients receive at least 1 medical intervention defined as a medication, IV, CPR, or advanced airway. We have many inexperienced providers.* There is minimal oversight in EMS. If a tree falls in the forest, does it make a sound? If a medic alone in the back gives the wrong medicine, did the patient receive it?
Sit around a table after work drinking beers with your coworkers and listen to the tales. It is the Wild West. Sure there are many medics – the majority, I believe — who do heroic deeds and provide professional care, but there are some other tales out there that would make shocking stories on 60 Minutes.
In the coming weeks I will be writing about Patient and Medication Safety. I will of course disguise all calls so that no person, service, or patient is identified. I will also try to make some suggestions about how to make EMS a safer place.
*You can be a medic for twenty years and still be inexperienced in what you are being faced with. I have only delivered two babies. I don’t care to ever see legs dangling out again. I have never done a surgical cricothyroidotomy. I hope I never have to cut someone’s throat because I can’t guarantee you, I will do it perfectly. We have a Melker kit. I am pretty skilled with it when I have practiced it five times in a room in a skills session. But a month later face me with a real patient who needs it now, and I am first day rookie.