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Measure Twice, Cut Once
You would most likely not be surprised if I told you that medical errors can impact patient survival. But you might be surprised to learn the extent of the damage. The Institute of Medicine reported the following:
“At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented.” (To Err is Human, 1999)
That might make you think twice about your next hospitalization. However, significant strides have been made since 1999 to decrease the number of errors that occur in our hospitals.
But how have developments affected out-of-hospital errors? How do you think we fare on scene or in the back of an ambulance — with only one or two EMTs providing care, often under harsh environmental conditions? While it is unavoidable that we will commit errors that impact outcome, what are these errors and how should we deal with them?
A consensus panel of EMS experts in 2002 identified the following errors as common sources for potentially serious adverse patient outcomes:
- Unsafe ambulance operations that endanger the patient, EMS providers and the public
- Failure to check oxygen saturation after endotracheal intubation
- Failure to immobilize
- Failure to check glucose levels in patients who are unconscious or have altered mental status
- Failure to detect misplaced endotracheal tubes
- Use of incorrect protocol or algorithm
- Administration of wrong drug or drug dose
- Failure to recognize patient deterioration
- Equipment malfunction
It should be no surprise that medication administration and endotracheal intubation were considered to be particularly error prone. Many medication errors can be averted in patients at the “extremes of age” simply by using a pediatric length-based weight tape to accurately determine dosage and recognizing an elderly person’s potential for an altered response to drugs. In addition to medication administration errors involving the six ‘Rights’ (right patient, right drug, right dose, right route, right time, right documentation), medication omission errors also occur, like failing to administer Aspirin to a patient with substernal chest pain.
Any provider using endotracheal intubation (ETI) in their practice should also have the ability to administer CPAP (continuous positive airway pressure). If you can avert the need for ETI by making the patient better with CPAP, you eliminate the risk of error associated with ETI. However, if you must proceed with ETI, it is crucial to have immediate access to airway rescue tools or techniques that may improve your success with a challenging intubation, such as a bougie, lighted stylet, or performing digital intubation.
When your best ETI attempt fails, you should always have an alternative airway in your bag, like a dual lumen tube and/or the laryngeal mask airway. Once you think you have successfully placed that tube in the trachea, you should hook up the capnography (preferably waveform) to confirm correct tube placement and monitor ventilation to maintain the appropriate CO2 level — and don’t forget to monitor oxygen saturation.
If you aren’t approaching ETI with these precautions, but feel you ought to, then you should discuss this with your medical director. They might be interested in the potential for safer, more effective patient care, and decreasing his or her liability at the same time. If your system is not already screening for the treatment failures listed above (and yes, transport is a treatment), then you should consider adding them to your quality improvement or performance enhancement process.
And while on the subject of process, are you comfortable reporting an error you have committed? You know medical mishaps will occur despite your best efforts to contain them. I am confident that anytime you happen to make an error during active patient care, that you will clearly relay that information to the receiving facility to optimize patient outcome.
But how about telling your supervisor or medical director? That particular action is dependent on your individual work environment. It’s much easier to spill your guts in a system where the primary focus is on continually improving patient care than in a system concerned with how best to punish a mistake made by a colleague.
We should all be considered colleagues — EMT, RN, MD — and interact in an equitable, responsible fashion. If our individual EMS systems are not made aware of patient care errors, and we are denied discussion of those errors in an open, honest manner to develop solutions to prevent — or at least decrease — error recurrence, then that system is broken and must be fixed.
The bottom line is that if we don’t learn from our mistakes, our patients will continue to suffer the consequences.
1. Institute of Medicine, To Err is Human: Building a Safer Health System, November, 1999.
2. O’Connor RE, Slovis CM, Hunt RC, Pirralo RG, Sayre MR. Eliminating Errors in Emergency Medical Services: Realities and Recommendations. Prehospital Emergency Care, 2002, 6:107-113
3. Hobgood C, Bowen JB, Brice JH, Overby B, Tamayo-Sarver JH. Do EMS Personnel Identify, Report, and Disclose Medical Errors? Prehospital Emergency Care, 2006, 10:21-27.
4. Rittenberger JC, Beck PW, Paris PM. Errors of Omission of Prehospital Chest Pain Patients. Prehospital Emergency Care, 2005, 9:2-7.
5. Vilke GM, Tomabene SV, Stepanski B, Ship HE, Ray LU, Metz MA, Vroman D, Anderson M, Murrin PA, Davis DP, Harley J. Paramedic Self-Reported Medication Errors. Prehospital Emergency Care, 2007, 11:80-84.