The 6 R's – Right Dose

Thoughts on Medication Safety — The Right Dose

I have given the wrong dose of a drug to a patient many times. Before you go demanding my license, hear my explanation. “The Right Dose” is about more than just accidental miscalculations. I haven’t miscalculated a dose that I can immediately recall. I did once however, trust a fellow medic who had drawn up a drug for me. I assumed he drew the drug up the same way I normally drew it up. Consequently I gave an inappropriate dose. My bad entirely. It was a cardiac arrest back in the days when we routinely gave epi down the tube. He drew up the epi and handed me the syringe. I shot it down the tube, thinking he had cut 2 mg of epi 1:1000 with 8 cc of saline. No, he had in fact drawn up 10 mg of epi 1:1000 and not diluted it at all. All my bad. The way he practiced was to draw up the 10 mg and then give it incrementally, so in other words, he had five doses in the syringe and did not bother to dilute it with saline. Not that it affected the outcome. The patient was in asystole when we got there and asystole after the 10 mg of high dose epi down the tube, and still asystole when they called her at the hospital. Still an error is an error. Not working regularly with another medic, I was off guard to his routine. I try to always be vigilant now when I have another medic on scene. If I am drawing up a drug for him, I say it out loud several times. If the medic is drawing it up for me, I ask several times to make certain it is the proper dose.

I carry my protocols with me – we have them on our laptops that we use to do our run forms – and I never hesitate to consult them to make certain I have the proper dose. I am not embarrased by this. I gave magnesium for asthma the other day – it worked great – I had to check the guidelines to make certain I was mixing it right (2 grams in a 100 cc bag). Having a calculator on the computer also helps for weight based drugs. I am particularly careful with pediatric dosing, which fortunately we don’t need to use much. A missed decimal point can be fatal to a pedi.

When I said I gave the wrong dose many times, what I meant was that while I may have given the right drug, I didn’t always give it in a dose that was effective for a patient. For years, once I finally started treating pain, I never gave enough. I have seen old run forms where I gave 2 mg of Morphine for an open tib/fib. That’s cruel. Now, I always ask the patient, “Would you like some more pain medicine?” providing I am still within the amount I can give in my guidelines. I regularly give 15 mg to larger patients in severe pain without contraindications. To give more I would need to call medical control. I probably should do that more because some of the patients need it. 20 or 25 mg might be the right dose for them.

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Writing this post my memory is flooded with other examples of the wrong dose, including ones which I had earlier denied – the miscalculation. I drew up narcan once in a one cc syringe thinking it was a three cc syringe and was surprised my patient didn’t wake up. (I was working at night then and not fully awake). I am sure there are others I have blocked from memory. I’ve had runaway IV bags dump many ccs of fluid into a patient that were not intended (That was mostly before we started using saline locks). And my drips, well, I have to come clean and say they are largely approximations. Dopamine, for instance, I ballpark and then titrate to effect. Unless we start carrying med pumps, that is probably the best I can do, although I should try to do better.

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As a clinical coordinator now I review run forms from three paramedic services. I don’t recall anyone reporting to me that they gave a wrong dose. I occasionally see wrong doses listed on run forms and had to do reeducation. As a region we give a protocol exam every time we change the protocols. The passing grade is 80%. Does that mean 80% of the time people get the right dose? And 20% they get the wrong dose? Or do people refer to their protocol books as I do when they are uncertain? Should passing be 100%?

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What does all of this medication safety rumination mean? For years, I didn’t give it much thought. Errors were a hazard of the occupation. I think sometimes we get caught up in the chaos, the uncontrolled environment we work in and use it as an excuse, forgetting that it is our job to bring order to that chaos, and our job to try to practice always to the highest standards.

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