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Medication Mistakes: bad employees or system flaws?

Scott Bourn

The agency’s Clinical and Education Coordinator got the phone call from Kyle, a paramedic, at 2:30 in the morning. Kyle reported that earlier in his shift he had cared for a middle-aged male complaining of cardiac chest pain. As part of his care, and in accordance with protocols, Kyle had administered 4 mg of morphine to the patient during transport. The medication reduced that patient’s pain from 7/10 to 3/10 and transfer of care to the emergency department went without incident.  However, during narcotic reconciliation at the end of his shift Kyle discovered that his count was over by 1 vial of morphine, and down by 1 vial of valium. After reviewing his calls for the shift (and fishing around in the sharps container) Kyle concluded that he had inadvertently administered valium rather than morphine to his cardiac chest pain patient.

What to do next?

Before continuing consider what YOU would do if you were the Clinical and Education Coordinator, or Operations Supervisor, or Medical Director? What would you say to Kyle? What investigation would you perform? What would you do to prevent this mistake from happening again?

The next day, after consultation with the Medical Director, the Clinical and Education Coordinator had a conversation with Kyle about his error. They discussed the importance of accurate medication administration and reviewed the “5 Rights” of medication administration: right medication, right patient, right dose, right route and right time. At the request of the Medical Director Kyle was asked to write a paper about the differences between valium and morphine, and the Clinical and Education Coordinator wrote a memo to all paramedics reviewing the “5 Rights” and reminding them to contact either himself or the Medical Director if they had questions or made a medication error. After submitting his paper about valium and morphine Kyle was allowed to return to duty.

What do YOU think?

Do you think the Clinical and Education Coordinator and Medical Director handled this incident in the right way? Do you think their actions will reduce the likelihood that a comparable error will occur in the future? What do you think Kyle learned from this experience?

Join “Preventing Mistakes for Better Patient Safety” to learn how your EMS agency can create a safe and protected culture of ownership and learning. Led by Dr. Scott Bourn, this one-hour panel webinar will take place on Thursday, November 29 at 1 p.m. CT. Register today.

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