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

- Rogue Medic

Preventing Medication Errors from Gathering of Eagles

There are some interesting case studies in this presentation.[1]

1. Rule out seizures, patient is waking up, then becomes combative, medication given IM (IntraMuscularly), combativeness continues, combativeness resolves, everything seems OK.

Later, the empty medication is found to be morphine, not midazolam (Versed).

There is a problem in giving the wrong medication. We need to be more careful about what we give.

Just because the packaging looks the same does not mean the contents are even remotely similar.

2. Rule out hypoglycemia, medication given IV (IntraVenously), but it was sodium bicarbonate, rather than D50W (50% dextrose), then D50W was given.

Similar appearance does not mean the drug is the same.

3. Rule out extrapyramidal reaction to psychiatric medications, medication given IV, the medication was 10 mg morphine, medical command was contacted, the appropriate 50 mg of diphenhydramine (Benadryl) was given.

Appearances can be deceiving.

We trust what we think we see, but our brains jump to conclusions on insufficient evidence. We need to find ways to prevent us from misleading ourselves.

It is interesting that morphine is the drug accidentally given in two of the three cases. It is expected that the morphine and midazolam would be stored together. The diphenhydramine might be stored with the controlled substances to make it easier to treat histamine release from morphine administration. There is plenty of time to get diphenhydramine after noticing a reaction to morphine. I do not know of any cases of anaphylactic reactions to morphine. Keeping the diphenhydramine with the morphine does not improve patient safety. If the controlled substances need to be opened each time that diphenhydramine is given, that is probably not going to please the DEA (Drug Enforcement Administration, the controlled substances oversight organization in the US).

The good news is that the sodium bicarbonate is probably only going to result in some hyperventilation to blow off the CO2 (Carbon diOxide) produced by the breakdown of sodium bicarbonate.

The boxes do not look the same, but . . .

. . . the syringes do look alike (except for the identifying labels).

All the fear of giving too much morphine , but when 10 mg IV morphine is given to somebody who has no medical indication for morphine, there are no complications at all.

None.

10 mg morphine was harmless, but some doctors still worry about giving 2 mg without orders.

The medical education provided by some medical schools has some blatant gaps in the area of pain management and pharmacology.

Some medics still worry about giving 2 mg without orders.

The medical education provided by some paramedic schools also has some blatant gaps in the area of pain management and pharmacology.

Footnotes:

[1] Preventing Medication Errors
Gathering of Eagles 2012
Page with links to presentations

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Comments

  1. All the fear of giving too much morphine , but when 10 mg IV morphine is given to somebody who has no medical indication for morphine, there are no complications at all.

    None.

    Interesting. But what if said patient has a sensitivity to opiates/opiods? Not with respect to overdosing someone on 2mg (not often but it probably happens), but with allergic sensitivity? Unless the patient can tell you, and knows that they have a sensitivity, it seems to me that this could be a potential wrinkle.

    Just a random thought as I read this post, RM.

    10 mg morphine was harmless, but some doctors still worry about giving 2 mg without orders.

    The medical education provided by some medical schools has some blatant gaps in the area of pain management and pharmacology.

    Some medics still worry about giving 2 mg without orders.

    The medical education provided by some paramedic schools also has some blatant gaps in the area of pain management and pharmacology.

    Unfortunate, but true. Lately, I have seen a number of new Paramedics on the service I work for come in with minimal pharmacology knowledge at best. Our clinical staff has had to fortify the pharm education some of these medics have, and it is disturbing. Additionally, the area I work in has multiple medical schools, and most of the hospitals act as teaching facilities. Many of them either do ED rotations or have a strong interest in emergency medicine. First year residents start near the fourth of July weekend, almost without exception. While some of these kids (they are young enough in most cases that they could indeed be my biological children) seem to have great heads on their shoulders, others are not so lucky. The third and fourth year residents, as well as the attendings, can have their hands full.

    • Walt,

      Allergic reactions are not harmless. They can complicate the management of any emergency medical condition.

      I have never even heard of an anaphylactic response to morphine. Allergic – rash, itching, maybe even a bit of wheezing, but never anything life threatening. That does not mean that the addition of allergy to an emergency medical condition could not produce a serious long-term adverse outcome (disability or death), but allergy is all I have ever heard of. I am not encouraging giving 10 morphine to everyone – the chronic customers would never stop calling – I am just pointing out that the supposed dangers do not even show up with healthy doses of morphine given inappropriately.

      The inability to produce an adverse event with misuse only highlights the safety of morphine.

      .

      • I have never even heard of an anaphylactic response to morphine. Allergic – rash, itching, maybe even a bit of wheezing, but never anything life threatening. That does not mean that the addition of allergy to an emergency medical condition could not produce a serious long-term adverse outcome (disability or death), but allergy is all I have ever heard of. I am not encouraging giving 10 morphine to everyone – the chronic customers would never stop calling – I am just pointing out that the supposed dangers do not even show up with healthy doses of morphine given inappropriately.

        Your point is well-taken. The only reason I bring it up is because of the possibility of something like that happening, and out-of-the-box things like that can, and do, happen from time to time. For what it’s worth, I have never seen an anaphylactic response to Morphine, or any other opiate or opioid that we utilize, either. But I try to consider the larger picture whenever I am looking at pain medication because weird things can occur, and believe trying to minimize that possibility is important.

        • Walt,

          We definitely want to minimize the possibility of adverse reactions, but we also want to maximize the relief of pain. The problem is finding the right balance of risk and benefit.

          I am just pointing out that we are still in the shadow of the hysterical hyperventilator and miles from the overly aggressive cowboy.

          We are not dealing with any rational balance of risk and benefit.

          .

  2. Perhaps the prevelence of morphine errors being recorded is the strict inventory control requires it? Accidentaly dosing something less tracked allows the administration to be hidden far easier.

    Just a thought.

    But reading the labels is kind of step 1…

    • Justin,

      I think that the DEA oversight is part of the recognition/reporting of errors involving controlled substances, but I do not know what criteria were used to choose these three examples. It may be that morphine errors would be expected to get more attention.

      It probably would not hurt to read the label each time we pick up a medication, so that we know what we have in our hands.

      Just a competence thing. 😉

      .

    • Actually, I witnessed a perfect example of this the other day with versed. The medic did not pay attention to the label (and therefore the concentration). He drew up what he thought was 10mg and gave half, as this would be the appropriate dose. However, the concentration was lower (5 mg in 1ml), so he only administered 2.5mg. Now, while I would say it’s better to give less than it is to give more, it’s still a grave error, particularly with something like versed.

      And 2.5mg was still enough to knock out this guy’s respiratory drive (he was on some good stuff, apparently).

      • kindofafireguy,

        As much as I like giving midazolam (Versed), it can be an unpredictable medication. Its absorption varies. The effective dose varies. The side effects can be the opposite of what we are giving it for. Some people become agitated with midazolam.

        I have never seen midazolam produce respiratory depression, even in large doses, but that is one of the advantages of midazolam – whatever happens tends to wear off quickly, because it is metabolized quickly. As long as we can mange airways, we should be safe with even large doses.

        .

        • Oh the medics and the FTO who also responded were all surprised. As I mentioned, he was combative (due, we believe, to the substances ingested). It was a very brief period of apnea (less than 5 seconds). However, the medic I was with thought to place the patient on end-tidal monitoring via nasal cannula, which is something he does with any drug with sedative effects as he believes it makes for much simpler patient monitoring (plus additional documentation when the monitor records it).

          The drug error was also caught, and documented. So I will say kudos to the crew for that.

  3. The first paramedic program I attended had one day of pharmacology. One.

    Mostly, it covered ACLS drugs, and a few RSI drugs.

    That’s it.

    I left shortly thereafter. My friends who finished said that was as far their pharmacology went.

    The second time around, I found a program where they use a pharmacologist.

    • We actually had a really good Pharm component – the chief hospital pharmacist actually taught the Pharm curriculum. We had to know all of the first-line drugs – ACLS, pain management, etc. – plus a number of second-line drugs as well as drugs used in the critical care setting. I believe at that time the total was approximately 35 medications we had to know. It was a lot of work – plus it was almost 10 years ago – but I learned a great deal.

      • Walt,

        I did not get a very good pharmacology education in paramedic school. I learned most from asking questions of pharmacologists, nurses, doctors, and reading FDA labels and reading research.

        There is a lot to keep up with, and it keeps changing, but we are taught pharmacology as if it does not change and it is simple –

        Give drug X for condition X and you will not get in trouble.

        I think that asking the question, What can I do to stay out of trouble? should result in immediate expulsion from any medical education course.

        There is NEVER any guarantee of safety of anything.

        If there were, EMS would not exist.

        .

        • I will say this: I have an excellent mentor who I work with. His biggest emphasis for pharmacology is that one should always be more aware of the effects of a drug and the “why not’s” for giving drugs rather than being so concerned with the “what” we give them for.

        • It sounds like the program I was in was the exception rather than the rule. And I think I was fortunate because what you all have described seems to be so commonplace now. My program got blended into a much larger, more regional program at a different hospital than where I went to Paramedic school. It is my understanding that the way you described your Pharmacology experience was much like what they are doing now. And that is a shame.

    • kindofafireguy,

      The first paramedic program I attended had one day of pharmacology. One.

      That is scary.

      The program director does not appear to understand pharmacology.

      If I were to run a paramedic program, the only sections I would give similar time to would be airway management (not just intubation) and research. If we do not understand how to interpret research, how do we understand pharmacology?

      All of pharmacology is based on evidence. There are many different kinds of evidence, but understanding how to put the different kinds of evidence into perspective is essential for understanding pharmacology.

      Mostly, it covered ACLS drugs, and a few RSI drugs.

      I don’t think that much time is needed on ACLS drugs, since there is not any good evidence that they improve outcomes. We seem to give them because the patient is too dead to run away and they help to change the documented vital signs – in the short term.

      Pharmacology is extremely important. Anyone who tells you otherwise is lying or foolish or both.

      .

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