May 4, 2013

Sedgwick County EMS develops process to reduce medication errors

99.879 percent. That is the Sedgwick County Emergency Medical Service’s accuracy rate of giving medication to patients it transports.

99.879 percent.

That is the Sedgwick County Emergency Medical Service’s accuracy rate of giving medication to patients it transports.

“But who wants to be the other .121 percent that gets the wrong dosage or drug?” said Paul Misasi, deployment and quality improvement manager for the county’s EMS.

Medication errors have long been an issue for all areas of health care providers, national observers say. And numerous methods have been tried in hopes of improving the accuracy rate, with varying success, they add.

Sedgwick County EMS appears to have come up with a plan that helps the cause significantly for emergency responders.

Two agencies – medical transports for the Mayo Clinic in Minnesota and in Arlington, Texas – soon will put into place a medication cross-check process recently developed by Misasi and Sabina Braithwaite, medical director for the county’s EMS System.

Another 16 agencies across the country have requested information about it and are considering adopting it.

The process involves a 20-second, scripted verbal exchange between two emergency providers.

“You don’t have time to do a cross-check that takes 10 minutes,” Braithwaite said.

The first verbal exchange comes from the provider who is about to administer a medication:

“Med check.”

“That lets the other provider know something important is about to happen,” Braithwaite said.

The second provider says, “Ready.”

Three more verbal exchanges follow. The last comment is from the second provider, who either gives the OK for the first one to administer the drug or calls it off.

Sedgwick County EMS responded to more than 56,500 calls in 2012. Its paramedics and emergency med technicians administer 1,300 to 1,500 doses of medications a month, usually by an IV or a shot.

Since Misasi began tracking errors in 2010, he said the county’s EMS has averaged one error every 28 days.

That average is dropping. Over the 13 months through this March, there have been 12 instances where giving medication was halted because the process caught a glitch.

“That means we avoided an error,” Misasi said.

The fact that the cross-check is verbal is significant.

“I think everybody was doing these things in their head,” said Crystal Macedo, who has been a county paramedic for five years. “But it helps to do it verbally. Someone else can check your work.”

Matt Will, who oversees training for the Mayo Clinic Medical Transport in Minnesota, became interested in the process after seeing Braithwaite demonstrate it about a year ago at a national convention. The agency is wrapping up training now and expects to implement the process over the next month, he said.

“It’s simple and gets results,” Will said. “Measurements actually showed it worked.”

Although the Institute of Medicine in 1999 issued the report “To Err Is Human: Building a Safer Health System,” which encouraged all health care providers to report medical mistakes, there are few firm statistics on the number of medication errors.

In 1975, the Institute for Safe Medication Practices, a Pennsylvania-based nonprofit, was formed in part so patients and providers could self-report medication errors.

“But we know what we get is just the tip of the iceberg,” said Renee Brehio, a spokeswoman for the group. “We don’t pretend to say we know what the numbers are. Our approach is that by getting the information on near misses and errors, we can help start a better educated process.”

That meant developing a process that went beyond the traditional method, known as the five rights of medication administration:

Right patient, right drug, right dose, right route and right time.

“How do I know I’m doing the right thing when I’m a stressed provider treating a patient in cardiac arrest?” Braithwaite said. “We need more than that.”

At the same time, Misasi saw a need to know some firm statistics in order to stay on top of the problem. That’s why he began tracking known errors by the county’s EMS a few years ago.

Two things prompted Misasi and Braithwaite to begin developing a new process in 2011:

• Periodically, the county’s paramedics and EMTs have their skills checked by supervisors. One of the tests is checking to see if they are giving the right medication and dosage.

“There were enough times that the provider thought they were giving one dosage when they were giving another that we were concerned,” Braithwaite said.

• The nation’s ongoing medication shortage provided a second red flag.

The shortage is created by a number of issues, according to medication officials. Price controls, regulations and fewer generic drug manufacturers are among them. Three companies produce 90 percent of the generic drugs, Braithwaite said.

The shortage has created problems for providers because it’s difficult to get a consistent stream of drugs from the same source, she said.

As a result, a vial of one medication may show up with a red top one week and with a blue top the next. Concentrations of the doses from one company to the next also vary.

Misasi and Braithwaite spent several months investigating what others had tried to improve accuracy. They picked up some ideas, disregarded others. They rewrote the verbal script three times.

At first, there was some pushback from providers about going through verbal exchange.

“Some were saying the patients are going to think we’re stupid because we’re doing the cross-check thing,” Braithwaite said.

But she also knew about her survey that showed all of her providers said they asked for medication verification.

“Yet, 40 percent said they knew they had made a mistake at some time in their careers,” Braithwaite said. “It’s more important to give the right dose than to give it very fast.”

The 20-second process strikes the right balance, she said.

Macedo, the paramedic, said the process helps “reassure everyone of what they are doing is correct.”

Braithwaite said she understands that it’s not possible to get an absolute firm number of medication errors.

“For one, you can’t report an error if you don’t know you made it,” she said.

But she’s tried to overcome another obstacle by not jumping to a punitive approach if an error has been made. Her providers are encouraged to report mistakes so everyone can learn how to do it better.

“You can’t fix what you don’t know,” Misasi said. “We want to know about the errors and what almost happened. Safety is the important thing.”

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