Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What is the Right Response to a Treatment Error – Part I

There is a recent example of a medication error that has received a lot of coverage.

When Melvin Davis was carried into the emergency room last Thursday, a doctor noticed something wasn’t right.[1]

It is usually not good when it is a doctor who notices a medic’s mistake. However, due to the lack of information provided, this does not state whether the medic noticed the error earlier or mentioned it to anyone. We do not know if the doctor noticed the error after the medic mentioned it to the doctor.

What we have been told is not much.

“Soon after we arrived at Erlanger with a patient, [the ER doctor] visually determined the wrong IV bag was hung and reported it to the supervisor,” said Chief Ken Wilkerson, who oversees Hamilton County Medical Services.[1]

The wrong IV bag?

What is the right IV bag?

It was a normal saline bag with a medication injected into it, but it was the wrong medicine and it was coursing through Davis’ veins.[1]


Why was it the wrong medication?

What medication should have been in the bag?

Should any medication have been in the bag?

Was the medication injected into the bag by the medic or was it injected by a pharmacist making a labeled pre-mixed bag?

The doctor notified the supervisors of paramedic Timothy Waldo and emergency medical technician Jamie Jackson. They brought Davis, 57, to the hospital after he was cut down from a rope tied around his ankle on a challenges course at Greenway Farms. Davis said he had been hanging there for two days.[1]

Here is an interesting problem.

Is the relationship between the doctor and the medic one where all communication is supposed to be between supervisors, who communicate with each other?

Is the relationship between the doctor and the medic more collegial? If so, the right thing to do may be to talk with the medic about the error and to allow the medic the opportunity to report the error himself.

More important than this error that seems to have been leaked to the press, is how an organization protects patients from future errors, rather than how the organization reacts to well publicized errors.

Has the organization done anything to prevent this kind of error from happening again?

I don’t mean the identical error, which everyone will watch for, at least for a while, but similar errors that may be expected with their system design. Is anyone doing anything to minimize future errors, or are they just dealing with errors after they happen?

Within 30 minutes, the supervisors took Waldo and Jackson off duty pending the outcome of an investigation.[1]

A medication error, but a basic(?) EMT is suspended with the medic?

There may be reasons for this, but in this case it appears to have been an example of over-reaction.

On Wednesday, Waldo, 46, was demoted to EMT after being a paramedic for as many as nine years. He also was suspended for 28 days without pay, placed on probation and ordered to undergo remedial training.[1]

Demoted to EMT

and

suspended for 28 days without pay

and

placed on probation

and

ordered to undergo remedial training.

Ordered? This suggests that the rest was not ordered. Is there any reason to believe that?

Such strong punishment suggests that the company is doing everything it can, not to protect patients from mistakes, but to protect the company from blame.

Don’t look at us – we were the first ones to cast a stone, and we used a lot of stones, that means we are pure and innocent!

I am just getting started, but you should also read what others are writing about this –

Too Old To Work, Too Young To Retire writes about this in Scratching My Head.

At Life Under the Lights, Chris Kaiser writes A Medic Roast in Tennessee. This post by Chris includes the Damoclean artwork to the right.

Footnotes:

[1] Tenn. paramedic demoted after drug mistake
On Wednesday, Timothy Waldo, 46, was demoted to EMT after being a paramedic for as many as nine years
By Beth Burger
Chattanooga Times Free Press
Article

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Comments

  1. Judging by the official overreaction, the patient must be Someone With Connections/Money, and not just some Joe from down the block….

  2. One thing I noticed was the supervisor:

    ….Wilkerson said the investigation did not take into account Davis’ condition after being given the incorrect medicine.

    “It’s hard for us to know what is the effect of the medication and not be able to account for other stuff,” he said. “What was taken into account was what occurred.”

    What the hell is “other stuff”? <- sounds really clinical.

    They say due to privacy they cant say the med? They already gave out all this other info about the patient and are hanging this medic out to dry. Whats the difference?

    Also, was there any harm done to the patient? Without knowing the drug and any outcome from giving it, how can they punish in the way they did?

    Drug errors are an issue. But if you give something that does no harm, shouldnt the punishment be inline with the error severity? Or do they exact this type of punishment for all medication errors?

    I'm thinking most of the time it's a QA/QI issue and since this was in the paper despite the "privacy" concern for the patient. It was addressed to the extreme.

    I just don't think there is enough info on either end to take sides with the patient, medic or the medics agency. But I am leaning towards the medic.

  3. This story rec’d alot of coverage not just because of the Paramedic. No, sometimes it is about the patient also. The fact that this man survived as he did was news worthy and then to survive a serious mistake by the Paramedic makes this an even better story…unfortunately.

    At the time this article was initially published very few details were known like was the EMT the one who spiked the bag and the Paramedic failed to check?

    Regardless, considering some of the headlines nurses have to endure including even pending criminal action and immediate revocation of their license for some medical errors, this isn’t too bad. Nurses also strive to catch mistakes and complain when the system is broken. Many in EMS just accept “that’s the way we’ve always done it” or practice “what happens in the truck stays in the truck” as the golden rule of protection. Time to change and move away from relying on excuses.

    Chances are he’ll be back on the job as a Paramedic as soon as he finishes his retraining. This was a company action and not a discipline on his license by the state. Nothing too uncommon about that except other med errors by Paramedics usually happen on patients who are not too news worthy and can easily be forgotten or written of by EMS.

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