Worst Patient Care Errors

[p3medic]

Yeah, we used to have the old brown vial of 1:1,000 epi, looks just like the lasix. As for the patient in my senario, to the best of my knowledge it went unreported, but I don't know that for sure. I do know that I didn't do the paperwork, I was there doing my required field hours, which documentation was not a part of it. I do know that today, if something like that were to occur, I'd own it, but day one in the field years ago, I had no interest in pursuing the matter, and left the two medics in charge to take care of things. It is entirely possible they owned up to it, as they didn't just unplug it again and throw a sheet over her.

[captainstandup]

Although I always advocate for standup (no pun intended) it would have been career suicide for you to get in the middle of this thing on day one. The problem you must remember is that in situations like this you are the one at greatest risk of being "thrown under the bus". Two seasoned and "tenured" employees could accuse you of making the error, then you would have no experience or credibility with the agency to defend yourself with.

Now that I work in the backstabbing equivalent of hell ( a hospital) I record about two thirds, or more, of the calls I respond to on a digital recorder and make notes in MS Outlook every single day regarding the days events. If anything out of the ordinary occurs I type up an incident report and keep it on file. I back all of this up once a week on a flash drive then on an external hard drive that isn't kept at home. I am especially diligent in recording and documenting when i respond to or transport a patient to an area, department or facility where I have had trouble in the past.

[p3medic]

Actually I don't, nor ever have worked for this department, it was an assigned field internship as part of medic school. It was the first call on the first day in the field, and in all the excitement my focus was on successfully managing the airway. After the tube was done, line had been established and a round of meds was on board. I then handed the airway off to the other medic and began to set up the epi and atropine bristojets while running though my asystole algorithm in my head. I remember I pushed the next two rounds of meds while the other medic set up the drip. I don't recall ever checking a pulse, ever. It was definately an eye opener, thats for sure. I am glad I was there, it has always stuck with me, and I tend to be very diligent in assessing the patient, regardless of what my technology might be reading.

[Just Plain Ruff]

P3 I get the picture now and I can see why you didn't report it. Please don't think I was taking you to task for not reporting it.

As a new guy and a new student it is overwhelming to begin to work in the field and then have this happen on your first day. Wow not what I'd want to happen.

I think that the learning experience for you that day was "what I don't want to happen to me" thing.

If it was several years down the road then that's a different story.

LIke I said, this thread is a tremendous learning opportunity for all of us. Let's keep this coming.

[Fluffpaw38]

Patient was placed on nonreabreather with the both the tabs still on it. the idiot EMT unplugged the oxygen without removing the nonrebreather so the patient was jus sucking the nonrebreather onto her face.....luckily i saw it and pulled the nonrebreather off her face till the oxygen tanks where switched. 8)

[Reddfrogg]

I was working ALS, we got a call to a doctor's office for chest pain. My partner and I walk in with the stretcher and hear from down the hall, the immistakable voice of an AED " Stand Clear, Analyzing Now"

We hurry inside the exam room to find the patient sitting up, looking around apparently in no distress. Pt is alert, oriented, and obviously has a pulse. He's got an NRB mask on, with the bag not inflated.

He's got AED patches on his chest, and the doc (or maybe PA, or Nurse practitioner) standing beside him. Fortunately, the machine says "No shock advised", and we take the pads off his chest. My partner asks "Why is he on the AED?" The doc replies ''Oh, just in case" In the mean time, I'm looking at the O2 flow, and I notice it's set to 2lpm!

For the sake of the patient, we got him out of there. He was discharged later from the ED, with non-cardiac chest pain....

[chbare]

A while back, I remember a story about an incident that occurred. A team was called to a hospital to provide transport to a larger facility with subspecialty resources. The patient was intubated; however, the patient was moving about the bed and fighting the staff. The crew asked if the patient had received any sedation, pain meds, or paralytics. The staff told the crew that they were giving Vecronium without any effect. A little investigation by the crew led them to find the hospital staff was actually administering Vancomycin.

Take care,

chbare.

[VentMedic]

As an RRT I had to give a deposition for a Combitube vs Larynx on a 20 y/o who just had a little too much alcohol to drink and was brought to the ED by ALS. It was placed by a Paramedic who thought the Combitube would prevent aspiration better if the patient vomited. (??!!?) The poor kid will not be using his own larynx to speak again.

I'm sure the Floridians remember this fairly recent incident.

Florida Woman: Paramedic's Error Caused Loss of Arm

http://www.emsresponder.com/article/articl...p;siteSection=1

Rebecca Mahoney, Sentinel Staff Writer

Orlando Sentinel (Florida)

SOUTH DAYTONA -- A violent stomachache prompted 84-year-old Marie Caschetta to call 911 in January 2006.

She expected to end up in a doctor's care. Instead, according to a lawsuit, she wound up losing most of her right arm.

Caschetta says a paramedic with Volusia County's ambulance service, EVAC, wrongly gave her a drug that can cause gangrene when improperly injected.

The South Daytona woman has since undergone three amputations, each time losing a different portion of her right arm, and she may face a fourth amputation that would take her elbow.

"I lost my whole life that day," said Caschetta, who is suing for an undisclosed amount of money. "I went in for a tummy-ache and came out without a hand. I'm an invalid."

The lawyer representing EVAC, Barbara Flanagan, declined to comment on the case. According to court records, however, Flanagan has argued that Volusia County, not EVAC, is legally responsible because its medical director sets the protocol for ambulance responses. County attorney Dan Eckert did not immediately return a call seeking comment Monday.

At issue is the paramedic's use of a medication called Phenergan or promethazine, used to quell nausea. If it is accidentally injected into an artery instead of a vein or a muscle, it can make arteries shut down and cause gangrene.

[mobey]

I was working ALS, we got a call to a doctor's office for chest pain. My partner and I walk in with the stretcher and hear from down the hall, the immistakable voice of an AED " Stand Clear, Analyzing Now"

We hurry inside the exam room to find the patient sitting up, looking around apparently in no distress. Pt is alert, oriented, and obviously has a pulse. He's got an NRB mask on, with the bag not inflated.

He's got AED patches on his chest, and the doc (or maybe PA, or Nurse practitioner) standing beside him. Fortunately, the machine says "No shock advised", and we take the pads off his chest. My partner asks "Why is he on the AED?" The doc replies ''Oh, just in case" In the mean time, I'm looking at the O2 flow, and I notice it's set to 2lpm!

For the sake of the patient, we got him out of there. He was discharged later from the ED, with non-cardiac chest pain....

This reminds me of when I got called to Doc's office for difficulty breathing and severe ABD pain. After a 1min assessment, I talked the woman out of hyperventilating and what do ya know, the abd pain went from 10 to 0 and she walked out to the rig!

[WANTYNU]

…… A local paramedic was treating a patient in severe congestive failure with profound pulmonary edema. Normal treatment …… 100 mg lasix …...

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

…… administered 10 ml of 1:1000 epi instead of the 10 ml of lasix.......

A partner of mine at the time was working for a different hospital, when the same thing happened, His partner, a perdiem, pushed the epi (worse yet you’re supposed to push lasix SLOOOOOW), this guy banged it. 10 mg of 1:1000 does not do good things to the heart.

Patient went into vfib arrest, flat lined and died… No happy outcome here, as he tells me the HOSPITAL buried it.

The story is plausible, at first I thought it was bull, as who would do something like that. I can’t really say since I wasn’t there, but we still carry the same vials of epi and lasix, and they do look similar, but since that story, I moved them to opposite sides of our drug bag.

-w