Continuing from Part I, Part II, Part III, and Part IV.
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Scapegoating. Thousands of years of tradition, unimpeded by progress.
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The only documented disciplinary incident in Waldo’s personnel file was in March, when he did not perform an inventory on an ambulance and there were major shortages, according to a report. He received a warning.[1]
he did not perform an inventory on an ambulance and there were major shortages
Did he go through an entire shift and not notice that significant portions of the ALS gear were missing? I would expect that in a medic/basic EMT system the medic checks out the ALS gear and the EMT checks out the rest. The BLS check should take less time.
Did he not restock at the end of a shift in which he used a lot of supplies?
What are major shortages?
Shortages of major importance?
A lot of things missing?
A lot of things of major importance missing?
Was there some kind of explanation for the major shortages?
Are the major shortages worse than a drug error that does not seem to have resulted in permanent harm?
Did the warning work?
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Back to the original issue. Apparently, a premixed bag of lidocaine was administered, when a bag of 0.9% saline was supposed to be administered? As I hinted at in Part IV lidocaine is a bad idea. Lidocaine is a bad idea in a syringe for a bolus dose. Since the only reason to use a bag of lidocaine for an infusion is to maintain the blood level of lidocaine provided by a bolus of lidocaine, the premixed bag is worse.
Is this the fault of the company?
Maybe.
The state may have a list of must carry drugs. Why they would include lidocaine is not a judgment call. Lidocaine and judgment do not go together.
The organization may not have any say in what the medical director does. However, they may point out to the medical director that this is a bad idea. Just because it is in the ACLS (Advanced Cardiac Life Support) guidelines does not mean that it is a good idea. There is a reason the guidelines are regularly updated. The problem is that the guidelines contain too many treatments that are based on wishful thinking, rather than evidence.
Most important!
What has the organization done to try to decrease the chances of a medication error like this happening again?
Anything?
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“Our goal is 100 percent success ratio and this is not the norm,” Wilkerson said.[1]
100%?
Perfection?
not the norm?
How about not possible?
Mistakes happen, Any organization that claims that it can prevent all mistakes is telling lies.
If there is no way of decreasing the systemic flaws that contribute to drug errors, then the solution of the company is to burn the scapegoat. This is not a plan that is safe.
The aviation industry has made tremendous improvements in safety in the last few decades. This happened by many different methods, but one important one is the focus on eliminating systemic problems that contribute to errors.
If you think that a drug error is serious, crash a passenger plane.
Who kills more people each year, airline pilots or paramedics?
We paramedics do. And we would be telling lies if we suggested that it is even close.
Other than make an example out of one paramedic, who clearly demonstrated that he is human, what has this company done to protect tomorrow’s patients?
Anything?
I don’t know, but there wasn’t anything about real safety in the article.
Rather than Monday Morning QB, perhaps some preventive medicine is what is needed.
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I think I am done, but be sure to 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.
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Footnotes:
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[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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I don’t know what you’ve seen, but I’ve been around to a fair number of systems and a lot of the privates don’t have/let the medics check their truck before they go, but have some other party do that before the medic gets there. Maybe this is one of those systems?
Thanks for this series of posts.
I would suggest when interviewing for a job as a paramedic and the employer asks, “Do you have any questions?” a good question a medic could ask is “How does this company, meaning everyone from top management to medics and EMTs in the field to billing to mechanics work together to prevent errors?” Followed up by, “What is the company philosophy about the reporting of and learning from errors?”
The answer to the question of what should we do with providers who make these mistakes needs to be preceded by the question on how do we prevent them in the first place. I agree mistakes will be made, its part of being a human being. Education, safety precautions and standards of medication administration are in place to avoid a deadly mistake. Paramedic student education regarding medication administration and pharmacology stresses the use of a systematic “6 rights” patient approach in conjunction with a “4 step” medication check. If this system is used 100% of the time we could eliminate 100% of medication administration errors and thus the question of what discipline should be appropriate would never have to be answered.
Here is the list of steps I am describing:
Patient 6 RIGHTS
– Drug
– Patient
– Dose
– Route
– Time
– Documentation
Medication 4 STEP check
– Solution concentration
– Expiration date
– Discoloration
– Particulate matter
When we make such comments regarding things like color of the tops of vials, color of boxes, labels and size as an excuse or explanation on why errors occur is baseless. Fueling the fire of complacency is the “benign” or “harmless” description of certain medications. Assuming a medication is the same medication, concentration, dose per cc/ml or is harmless based on past use or packaging is a dangerous behavior.
Why is it difficult to follow a standard of care that works and prevents or reduces the chance of an error like this? If a Paramedic deviates from the standard of care the consequences can be disastrous for the provider, profession and most importantly the patient. In the case you discussed on the show I don’t feel enough information has been provided to make an educated guess on what occurred and I am reserving my comment until more information is provided.
To be considered professionals we have to raise the bar, not find ways to lower it. I don’t feel that asking a provider to administer a medication correctly 100% of the time is unfair. We ask an airline pilot to land the plane safely 100% of the time, would you feel comfortable if the pilot just assumed a runway was clear because he has been landing there for years?
I my own mind I am a professional EMS provider, but until we take responsibility for our actions, correct inadequacies and allow transparency of the service then only will the administration of pre-hospital care become scientific, uniform and successful, when it is raised to the status of a profession, and people specially trained for it, show unity in the profession, and gain the publics respect as done in other aspects of health care professions.
Make changes, not excuses.