Can we do more to reduce medication errors?

By L.J. Relle, BBA, NRP, FP-C, CCP-C

When a prehospital clinician arrives at a scene – whether it be a roadside, residence or a major industrial accident – chances are that the care environment is far from optimal.

During this time, the nature of the surrounding environment and the patient’s underlying issues can contribute to a rapid deterioration in patient status. Making matters worse, responders can also face extremes in weather ranging from scorching heat, numbing cold or gale-force winds, as well as emotional responses from friends, family members and bystanders as they apply care. With all this in mind, there is one constant that remains throughout the care process: every second counts.

With the clock ticking, every responder is faced with a terrible dilemma: get the patient to the closest appropriate emergency department – possibly causing delay and deterioration – or provide immediate and stabilizing treatment at the scene with the risk of making errors. EMS teams must assess the scene, gain access to patient(s) in need of care, make a field diagnosis and treatment plan, begin treatment and then navigate the transport of the patient(s) to the hospital.

Treatment delivery speed and accuracy are essential components to providing effective care. The unfortunate reality is that these crucial elements rarely go hand in hand when providing emergency care, as stressful, volatile environments can lead to mistakes, including medication dosage errors. In many cases, prehospital clinicians have to make manual calculations, taking into account the patient’s weight, the recommended dosage and other factors while the seconds tick away and the risks increase.

According to a survey in San Diego County (Vilke et al, 2009) 9.1% of responding paramedics reported committing a medication error over the previous 12 months. The types of errors include:

• Dose-related errors (63%)
• Protocol errors (33%)
• Wrong medication errors (4%)

Issues identified as contributors to medication errors include:

• Failure to triple check
• Infrequent use of the medication
• Dosage calculation error
• Incorrect dosage given

Another study (MW Hubble et al, 2000) tested the drug dosage capabilities of 109 practicing paramedics. The average drug calculation examination score was 51%, with fewer than 30% of participants scoring 70% or above. The researchers found that paramedic calculation performance was poor, with intravenous flow rate and medication bolus problems calculated in 68.8% of the cases. These miscalculations can lead to additional patient deterioration.

Additionally, a more recent peer-reviewed article (Loner et al, 2018) found significant variation in IIFR (Intravenous Infusion Flow Regulators) volume observed across all devices and flow rates even in static, laboratory environments. These findings add caution to the use of IIFRs overall, as they could lead to inaccurate medication dosing (both over, or under-dosing) in the prehospital environment.

Reducing dosage errors with pre-hospital infusion pumps

Throughout my career, it has become an obvious and reoccurring theme that prehospital clinicians have pretty much been on their own – save for their training – performing calculations to the best of their ability in sub-optimal conditions. Luckily, it doesn’t have to be this way going forward as several tools are emerging to arm paramedics with significantly more accurate drug calculation capabilities to help prevent medication dosing errors. Advances in infusion pump technologies that cater specifically to the prehospital environment can play a significant role in enabling rapid and accurate medication delivery in emergency situations. This includes electronic pump systems with preset programming and access to an integral drug library that can make IV Infusion therapies and treatment possible with confidence and safety.

Electronic IV infusion pump systems now have access to drug libraries that contain information about customized groups of drugs and clinical care areas (CCA). These CCAs can be approved and saved by local medical direction, pre-defining the dose and hard or soft limits. They can display concentrations, dosages and safe ranges for medications and other parameters such as continuous rate, bolus administrations. The drug library can function as an error-reduction tool. If a clinician starts to exceed the dosage, then the pump will limit delivery, similar to a speed-limiter in a car, which governs the top speed.

Medical device manufacturers should tailor existing technology to fit the need of the pre-hospital environment. Infusion pumps need to be outfitted with the proper infusion sets and accessories to reduce all possible errors that may occur and promote optimal care, no matter the physical surroundings. The more these systems can be automated with preset and pre-programmed drug libraries, the more we can prevent errors in fast-paced emergency response scenarios. Where every second counts, it is crucial that our EMS teams be provided with the right tools that help prevent making manual calculations in stress-filled circumstances. Our patients’ lives often depend on it.