Do You Report Medication Errors ?

[crotchitymedic1986]

I am not asking whether or not your service has a policy, but I am just wondering if our culture has changed from covering-up these errors, to a position of reporting every single medication error. Obviously, if you were to give a lethal dose of medicine, I believe everyone in this forum would report it to protect the patient's life, but what do you do if it is a simple error without a negative outcome. What if you gave a patient atrovent instead of xopenex or other respiratory aerosol treatment ? So my questions are:

1. Have you reported or do you report every medication error that you know of ?

2. What does your service do to minimize the possibility of medication errors ?

3. If you do report such errors, are you punished by your service (most hospitals have moved to a non-punishment policy because they want the errors reported so that they can find ways to minimize the reoccurence of that error by someone else) ?

[FireMedic65]

1. ABSOLUTELY we are not criminals. If mistakes happen, and they do, we document everything, not matter what.

2. Training, education, common sense, know how to READ.

3. If you make a mistake, you shouldn't necessarily be "punished". Depending on what you have done. If you give say an ACE inhibitor to a patient that you didn't know was pregnant by either them not knowing in early pregnancy or you forgetting to ask. I don't see a reason to "punish" the person who gave the medication. If anything, they be required to do some sort of in service on giving medications, the whole R thing.. Right dose, Right patient, Right medication, etc etc...

Now, if you have given the patient a BETA blocker, Adenosine, or Verapmil, to a patient that is bradycardic or giving a patient who is having chest pain Asprin and they say they have an ulcer or are allergic, these would be highly ignorant of the person giving the medication and should be dealt with in a more appropriate manner.

[crotchitymedic1986]

But if you punish when they report, many people will just not report the error. The Five R's is a good thing, and has been around a long time, but it is not stopped all errors. Just google Heparin and read all the mishaps from nurses giving the wrong concentration and killing patients, because the bottles used to be almost identical in size and labeling.

Edited March 23, 2009 by crotchitymedic1986

[HellsBells]

Now, if you have given the patient a BETA blocker, Adenosine, or Verapmil, to a patient that is bradycardic or giving a patient who is having chest pain Asprin and they say they have an ulcer or are allergic, these would be highly ignorant of the person giving the medication and should be dealt with in a more appropriate manner.

I would argue that these are not mistakes, so much as medication errors borne of ignorance. If one is foolish enough to give such innapropriate drugs, I'd argue that it would be unlikely that they are the type of person to report medication errors. Particularly if he is giving ASA to a patient who just said they have an allergy.

On the other hand, if the error is made due to a labeling problem, i.e. he though lopressor was atropine because the vials look the same, then its a system error and should not result in punishment.

To answer the question, Yes I would report a medication error, no matter how little harm the pt may be facing from my error.

[Just Plain Ruff]

I report all med errors I make, I make very very few but here is one where another person would probably gloss over.

I had a 3 year old patient and I went to give motrin suspension. The dose was for 5ml rather than 7.5ml but I inadvertently gave 7.5ml of childrens motrin. The fever was 103.5 and the order was for 5ml.

I told the doc, he said, no big deal. I documented anyway.

[WolfmanHarris]

Base hospitals have self-reporting lines as part of the QA process that allows Paramedics to report their own errors and work with Base Hospital to address any underlying issue.Beyond that I couldn't tell you much as I don't yet work for a service, so don't know the exact policies.

If I made a mistake I would report it. In fact I think we need to copy the airline industry and start making it part of our culture to report all mistakes and near-misses in order to be constantly searching for ways to prevent them. I haven't yet made a medication mistake outside of class, and the one's I've made in class that I've caught I've always verbalized and attempted to fix as I go. If and when I make a medical mistake in the field, I intend to report it.

[firedoc5]

We had the same exact topic about a year ago. But it's good to refresh some of them from time to time for newer memebers and to keep it fresh in our minds.

[Mateo_1387]

I have been lucky to not make a medication error as of yet. Hopefully, it will not happen either.

The service I am currently with does not have a set way to report medication errors. If I did make an error, I would document it and pass it along to the nurse.

In the service I used to work with, they required that as soon as you realized you did something wrong, that you immediately call up the Medical Director to report it. The reasoning behind this is because the medical director needs to know immediately what happened so that he could discuss with the patient's physician the issue. Of course, it is also required to document the error. The old service expected everyone to report their errors and made sure to let everyone know that reporting did not mean they were going to get 'fried' by administration. They would however, if it were a major problem, recommend some remedial training that was supposed to work in a positive manner, and not a negative one. Of course if the issue persisted, they would of course address the best way to correct the problem.

[Kiwiology]

Are you kidding, that would make me look bad!

We report it to our medical director but we also have "clinical standards" people who are a waste of time that take Paramedics off the road and shove them behind a desk, could go see them.