Worst Patient Care Errors

[captainstandup]

What are the worst patient care errors, mistakes, screw-ups you are aware of?

BEAR IN MIND THERE ARE LIKELY OTHERS ON EMTCITY THAT MAY BE ABLE TO LINK A SPECIFIC CASE BACK TO YOU IF YOU PROVIDE IDENTIFYING INFO SUCH AS COUNTY, CITY, TOWN, SERVICE NAME ETC. BE CAREFUL NOT TO INCLUDE ANYTHING THAT COULD BE A HIPAA VIOLATION AND NEVER MENTION ANOTHER PROVIDER OR SERVICE BY NAME. DONT SAY ANYTHING THAT COULD COME BACK TO HAUNT YOU!

My intent is to have a discussion of errors that happen in EMS or a related discipline. Through this discussion perhaps we can all learn, or at least pause for a second a remind ourselves, to be very diligent in the accuracy and appropriateness of the care we deliver.

[pacman]

Alright I'll break the ice. Many EMS providers don't seem to properly secure their patients, and I learned the hard way.

I once responded to a two patient MVC at a major highway in NJ. ( how more vague could I get?). Both patients were BLS only and were going to be transported to the same hospital, so we decided to have them both transported in the same ambulance. I cancelled the second oncoming unit. We backboarded both patients and put the less serious patient on the bench seat. The second patient, still bleeding from a facial laceration was secured on the cot.

During transport, my partner took a turn too quickly, and I noticed that the backboarded patient on the bench was sliding off the bench!! :shock: I quickly dove over the patient on the cot and caught the second patient and backboard before she slid off the bench completely. I don't think I've ever reacted that fast! It turns out that I didn't secure the patient onto the bench with the seatbelts.

We all got to the hospital safely, but couldn't get it off my mind how bad the call could have become if I didn't catch that patient in time. I'd be paying the legal fees till the day I die! The lesson learned from that was to always secure the patient before and immediately after you move them instead of having the whole " I'll get to that in a bit" mentality.

[Just Plain Ruff]

i know of two cases

1. a nurse in a town(vague) gave sux to a patient in x-ray and then walked out. Don't know if it's just an rural legend but you get the idea.

2. I know of a medic who nearly gave potassium iv push.

[mobey]

EMT was "riding th rail" doing CPR on a pt secured to a newer style ferno cot. Going down the hospital hallway they took a corner to fast and flopped the whole cot over....Lesson learned (lower the cot)

[EMS49393]

This near miss happened to me while I was hospitalized with kidney stones. While on my way down for stent placement, I was offered two pre-procedure PO medications. Being the ever cautious paramedic I am, I asked what I was being fed. The nurse responded "Pepcid and Reglan." I'm allergic to Reglan, and this was documented in my chart. The nurses failed to give me an allergy bracelet, and the doctor failed to inspect my past medical history.

To make matters worse, I was supposed to have lithotripsy along with stent placement. The urologist had my records from my ER visit two days prior. These outlined what medications I had received, etc. Turns out you can't have lithotripsy if you've had any NSAIDS. I had been given Tordal in the ER. Because this doctor over-looked (or never looked at) these records, I was sent to a hospital I wasn't crazy about instead of the one I like very much. Subsequently, I had the worst hospital stay I have EVER had, and with over fifteen blood transfusions in the past six years, I have enough experience to know good from poor treatment.

Needless to say, that hospital is under JCAHO review now, thanks to me.

[JPINFV]

Well, my Mom was hospitalized for almost a year growing up after she had two strokes. When she had the first one, her airway swelled shut and the ER physician ended up having to trach her (EMS doesn't have surgical airways. According to people who were at the event she was helping to run, EMS arrived and left within 5 minutes of being called). Well, she was never put into soft restraints. When she started coming around that night in the ICU, she wasn't really pleased that she had a tube going into her neck and successfully removed it. That earned her the chance to get discharged almost a year later following rehab with a shiny metal airway still in place. Eventually, she was able to have constructive surgery to fix her trachea.

[DwayneEMTP]

56 y/o male, difficulty breathing, history of asthma. Continuous albuterol neb during 15 min transport without checking lung sounds.

(No, not my patient)

Actual condition? Undiagnosed CHF with ( I can't remember the location) STEMI.

Nuff said?

Dwayne

[p3medic]

While riding 3rd in a city somewhere in New York state, went to a cardiac arrest. Patient was an elderly woman, apneic on the floor. Being the first call of my first day, I was very excited at the prospect of getting an intubation on day 1. Anyway, tube in, pt asystolic on monitor, LP5, three rounds of drugs and an isuprel drip per local protocol. Well things weren't looking good, nice flat line on the monitor screen, too flat infact with all that good cpr taking place. While the medic on the radio was getting orders for field termination, I noticed the lifepak cable was attached to the pt, but the other end was stuffed in the pouch on the case, not inserted in the machine! :shock: Well, I reach over and plug it in, she's in a narrow complex tach at 200, great blood pressure, still apneic. We took her to the hospital, no one the wiser. Lessen: Always assess the patient.

[Just Plain Ruff]

p3medic, did you do cpr on this patient?

If so how did you document that the life pack cable was not plugged in and you were working a code on a monitor that wasn't plugged in?

Or did you guy just cover it over and go on your merry way.

I'm not criticising you but I'm curious as to how you guys addressed this error?

This thread is a great thread, and thanks Cap for starting it.

I think that along with pointing out what errors we've done or what errors we've seen happen, how we address them or take responsibility for them is key here.

For the potassium chloride example that I posted, the hospital (yes it was where I worked but not me who was going to give the KCL) changed their processes so only pharmacy could mix up a iv with KCL in it. Take out the middle man and your problem is basically solved.

The drug company put on the metal band near the medication draw out port the words "MUST BE DILUTED" on them. The drug company also recommended to all pharmacies that this medication should only be diluted by a licensed pharmacist.

We need to learn from our mistakes, we need to take responsibility for our mistakes and own up to them.

If you cover them up it makes you negligent and in my opinion a danger to patients out there. If you cover up a mistake, what else are you covering up.

I made a drug error myself a long time ago that still haunts me.

I had a ecclamptic patient(sic) who went into grand mal seizures. I had standing orders for Valium 5mg as needed for seizures. Well she seized and I grabbed out of the narc box a syringe of morphine rather than valium. I gave 5mg's morphine to thiis patient. Soon after her seizure stopped and we arrived at the hospital .

shortly after cleaning up the truck my partner came to me and said "why did you give morphine to her" and I said i did not. He showed me the syringe. I about passed out. I was not concerned about the patient but I was terribly concerned for the baby.

I went in the ER, found the doctor taking care of her and told him what happened. His answer to me was "No wonder why her pupils are pinpoint" and then he proceeded to talk me thru this. He could see that I was very worried and he assured me that nothing happened to the baby.

I then called our supervisor and relayed the issue to them and had to write up several incident reports on this as well as a incident report regarding why they would be short on their narc count morphine.

The doctor called the quality control person at our EMS service and commended me on coming to him so quickly and taking responsibility for the error because I could have covered it up but did not.

Did I get some remedial training? yes Did we change our drug narc boxes and processes Yes - they put large labels on the sealed narc vials so even if we grab the wrong medication we can see the name of the medication on the seal.

Positive changes happen from mistakes but only if we address those mistakes.

I've always said, Actions have consequences, it's how you want to deal with those consequences.

[captainstandup]

One of the reasons behind my OP was an incident that occurred many years ago which received a great deal of "rumor coverage" but no media coverage. Let me begin by saying I wasn't working the day this happened. A local paramedic was treating a patient in severe congestive failure with profound pulmonary edema. Normal treatment would have, in that day, been High flow oxygen, SL NTG, 100 mg lasix and if indicated intubation.

Important note: We carried "mega dose" vials of 1:1000 epi (30 ml). I'm sure you can already see where this is going...

The medic applied NRB @ 100% , gave the patient 0.4 mg SL NTG, Initiated IV and administered 10 ml of 1:1000 epi instead of the 10 ml of lasix he believed he was administering. Almost instantly the medic caught his mistake and according to his partner began losing his mind!

The medic admitted his mistake and his paramedic certification was suspended for a year, by the medical director, but he didn't loose his job. The service actually permitted this guy to work as an EMT-I. The best part of the story is that the patient survived and the service didn't get sued. Good news is the error never had any media attention.

Lessons Learned by this guy, at least I hope he learned them! Just because its in a large brown vial, it's not necessiarily lasix, although i must mention the epi vial was significantly taller than the lasix vial. Oh! I failed to mention the epi vial had Epinephrine 1:1000 on the label and the Lasix vial had, ahhh errrrr, well it had Furosemide on its label. Apart from these three things they were identical, similar, ok they were nothing alike and this guy is a dumbass..........

What were those five patient rights pertaining to medication administration again, hmmmmm........................................................................