ERRORS IN EMS

1. Sheri Stringham ERRORS IN EMS

3. Have you ever made an error while working on a patient?

5. Case Study • A case was tried where a 10-month-old girl suffered anoxic brain injury after “being deprived of oxygen for 40 minutes after ambulance attendants got lost on the way to the family's house, forgot the keys to an onboard medicine cabinet and later falsified records related to the rescue”

6. Medicolegal Outcome • The girl, now 5, is a spastic quadriplegic with severe brain damage • State health officials heard of the case only after a story appeared in the state Lawyers Weekly • The $10.2 million settlement included a confidentiality agreement that kept secret the identities of the family, the ambulance company and the EMS technicians

7. Errors • Not all errors result in harm to the patient, and many EMS agencies react only to errors that are considered to have an adverse effect on a patient (injury or death)

8. “Mandatory reporting of EMS errors sought”By JOHN McELHENNY, Associated Press writer12-19-01 • ----- Ambulance companies and emergency medical technicians would be required to report mistakes made on medical calls, according to regulations proposed by state health officials yesterday The move is partly a response to a multimillion-dollar settlement between an ambulance company and the family of a 10-month-old girl after a delayed rescue • Officials hope to enact the new regulations by April

9. Mandatory Reporting • Under the proposed regulations, ambulance companies would be required to report cases resulting in "serious injury to a patient not ordinarily expected as part of the patient's condition" • That would include delays, errors in administering medication, and equipment failure

10. How do you fix this? • Why did they get lost? Was this the first time? • Why were EMS personnel locked out of their medication cabinet? • Why were the records falsified? • Why did the health department react this way, and only after the case appeared in the ‘lawyer’s weekly’

12. Occupy down time productively • Having nothing to do produces boredom or anticipation • Boredom is exhausting • Anticipation is exhausting • Exhaustion can lead to errors at the wrong time

13. Check equipment, vehicle • Is everything there? • Does it work? • Do you know how to work it?

14. Know your response area • Look at the map • Drive the routes • Know changes in traffic patterns with times of day • Have resources available for special problem areas (apartment complexes, colleges, industrial sites)

15. Weather awareness • Temperature • Humidity • Are you dressed for the occasion? • Are you staying hydrated?

16. Maintain you knowledge base • Journals • Videotapes • Internet • Conferences/CEU’s

17. Crew condition • Fatigue • Hunger • Thirst • Illness • Preoccupation • Complacency • Responsibility and obligation of provider to know when they can no longer perform optimally

18. Good communication a key component in making positive differences Confirm medication orders, reaffirming protocols, and repeat information back to a patient to ensure it has been heard correctly Communication

19. Teamwork • Can decrease certain types of errors • Acting alone or without support can lead to patient care problems on a number of levels

20. Quality improvement programs • Identifies problems • Establishes procedures for improvement

21. Resuscitation from Cardiac Arrest • Bystander Recognition and Assistance • 911 Access • First Responders • AED Programs • EMT Response • Paramedics • Hospital

22. Case Example • 911 call: 58 y/o male c/o chest discomfort • EMS arrival: patient is pale ashen diaphoretic • History: renal failure and hypertension • BP 70/30, heart rate 36 • Thready pulse

23. Case Example • During assessment patient become more lethargic and stops breathing • No response to epinephrine, atropine, or pacing • Endotracheal intubation performed • Transported CPR in progress

24. Case Example • On hospital arrival • no response to CPR • asystole • ET tube placement checked by direct visualization • esophageal placement suspected • reintubated • CPR continued but unsuccessful

25. Case Example • Paramedic saw tube go through cords • O2 Sat undetectable • ETCO2 (colorimetric) was equivocal • When did misplacement occur? • From the outset? • During CPR? • During stretcher transfer?

26. Airway Management • Physical Diagnosis • Esophageal Detector Device • Capnometry • Capnography • Direct Laryngoscopy • Fiberoptic visualization

27. Unrecognized misplacement of endotracheal tubes • 167 out-of-hospital EIs were recorded • 136 (81%) were deemed successful by EMS personnel • 12% (13 of 109) were found to have misplaced endotracheal tubes • 9% (10 of 109) were in the esophagus • 2% (2 of 109) were in the right main stem • 1% (1 of 109) were above the cords Acad Emerg Med 2003 Sep;10(9):961-5

28. ETI experience • Recent American Heart Association (AHA) guidelines have suggested that advanced life support (ALS) providers should have "regular field experience," defined as six to 12 intubations/yearRural EMS providers rarely use EI skills, particularly in pediatric patients

29. Prospective, multi-centered evaluation of out-of-hospital endotracheal intubation using a standardized data collection tool • The overall reported ETI success rate was 86% (92% for cardiac arrests and 76% for non-arrests) and did not appear to vary between population settings • There were two cases of delayed recognition of esophageal intubation, one case of unrecognized esophageal intubation, and 22 cases of tube dislodgement during patient care or transport Resuscitation 2003 Jul;58(1):49-58

31. ETCO2 3-14 mmHg?

32. Solutions? • Multiple methods of confirmation • Rely on best method • Digital capnography? • Continuous monitoring • Immobilize patient • Frequent reassessment

33. Unrecognized Hypoglycemia • Coma • Altered Mental Status • Seizures • Stroke Syndrome • Infants • Hypothermia • Lethargy

34. Medication Errors • Incorporated doses algorithms into cardiac monitors • Rhythm-based algorithms • Automated dosage calculation • Packaging strategies • Pediatrics: length-based and color-coding

36. Case example • 911 call: 23 y/o female unrestrained driver in MVC • EMS arrival: ejected, GCS 12, moans when abdomen palpated BP 80/50 • Taken to nearest hospital • CT down • Transferred

37. Case example • Arrests en route • Arrives at Trauma Center 3 hours after the crash • Can this happen?

38. The minimum criteria for the definition of a major resuscitation are as follows: • CONFIRMED Blood pressure < 90 at any time in adults and age specific hypotension for children; • Respiratory compromise/obstruction and/or intubation; • Transfer patients from other hospitals receiving blood to maintain vital signs; • Emergency physician's discretion; • Gunshot wounds to the abdomen, neck, or chest; • GCS < 8 with mechanism attributed to trauma

39. #!@##

40. Blunt trauma - MVC • Mechanism of injury • Tire Marks • Passenger compartment intrusion • Interior deformity • Side vs. front vs. rear impact • Rollovers • Restraint use • Airbags (deployed vs not)

42. Patient Non-transports • Leaving the patient at the scene against medical advice was associated with the absence of the following factors: • family on the scene and a police hold, and with the presence of the following factors: treated hypoglycemia, alcohol use, orientation, and normal speech • Statutes that allow police hold placement under the guidance of the base station physician may be necessary Stark G, Hedges JR, Neely K, Norton R Patients who initially refuse prehospital evaluation and/or therapy Am J Emerg Med 1990 Nov;8(6):509-11

43. Standing Orders • Standing orders were developed for 7 medical chief complaints and all major trauma patients • There were 13,586 EMS incidents, of which 4,037 (30%) received ALS treatment • SOs were used on 2,177 of these incidents, representing 54% of all ALS runs and 16% of all EMS incidents • The most frequently were for altered level of consciousness (29%), and chest pain (25%) Eckstein M Implementation of standing field treatment protocols in an urban EMS system Am J Emerg Med 2001 Jul;19(4):280-3

44. Standing Orders • The most common errors found were • failure to document reassessment of the patient after each medication administration (45% fallout rate), and • failure to document and attach a copy of the ECG to the EMS report (40%) • The mean fallout rate for failure to establish or attempt IV access, administer oxygen, or provide cardiac monitoring was 7% Eckstein M Implementation of standing field treatment protocols in an urban EMS system Am J Emerg Med 2001 Jul;19(4):280-3

45. Standing Orders • Out of 1,450 incidents with outcome data provided by the receiving hospitals, only 3 cases involved incorrect treatment Eckstein M Implementation of standing field treatment protocols in an urban EMS system Am J Emerg Med 2001 Jul;19(4):280-3

47. Ambulance Crashes • 339 crashes caused 405 fatalities and 838 injuries • These crashes occurred more often • between noon and 6 PM (39%) • on improved (99%), straight (86%), dry roads (69%) • during clear weather (77%), while going straight (80%), through an intersection (53%), and striking (81%) another vehicle (80%) at an angle (56%) • Most crashes (202/339) and fatalities (233/405) occurred during emergency use Kahn CA, Pirrallo RG, Kuhn EM Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis Prehosp Emerg Care 2001 Jul-Sep;5(3):261-9

49. Ambulance Crashes • Occurred significantly more often at intersections, at an angle, with another vehicle • 30 pedestrians and 1 bicyclist = 9% of fatalities • In the ambulance, most serious and fatal injuries occurred in the rear (OR 27 vs front) and to improperly restrained occupants (OR 25 vs restrained) • Sixteen percent of ambulance operators were cited; 41% had poor driving records Kahn CA, Pirrallo RG, Kuhn EM Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis Prehosp Emerg Care 2001 Jul-Sep;5(3):261-9