CASE STUDY REVIEW
Let's reconsider the initial case reported through the MEPARS system and see how it is resolved using the systems approach. An analysis of the event revealed that there was no procedure to double-check the medication prior to its administration; the medications were in similar vials with similar labeling; there was miscommunication between the providers regarding the drug needed; and it was normal procedure in this EMS agency for BLS providers to draw up medications for the ALS provider. Another contributing factor was that the dermatologist's mistaken diagnosis of anaphylaxis (rather than a normal reaction to inadvertent intravascular injection of epinephrine) influenced the paramedic's assessment of the patient. Based on the lessons learned from this event, several "system fixes" could be implemented to avoid similar future events. For example, ALS providers should always prepare their own medications. Similar vials could be modified with different colored labels or by purchasing the medications from different manufacturers. In an EMS system where 1:1,000 epinephrine is only administered in doses of 0.3 mg or less, it should not be available in 1 mg vials. If administration of 1:1,000 epinephrine is not allowed intravenously, make it available in prefilled syringes that can only be administered intramuscularly (such as an EpiPen).
If this case was resolved using the blame-and-shame approach, the results would be far different. The EMT and paramedic would immediately be identified as culprits. The BLS medic would be blamed for breaking policy by drawing up medications; the paramedic would be blamed for allowing the BLS medic to draw up the medication, as well as for not verifying the medication before administering it. Both people might be terminated, and the agency would feel it had resolved the issue with no further motivation to find avenues of system improvement and no protection from the same event occurring in the future or in a different EMS agency.
The road to creating a safe environment for patients will involve a change away from our current EMS culture where near-miss errors are rarely reported, usually due to fear of punitive reaction from peers and supervisors. Rather than blaming individuals for errors, we should look at what system changes can be made to reduce the chance of the same error occurring, or ensure an error does not result in an adverse event. Through an event-reporting system like MEPARS, a much-needed transition can be made away from the flawed blame-and-shame, and system problems can be identified and addressed nationally so EMS agencies everywhere can improve the safety of their systems.
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Karthik Rajasekaran, BA, EMT, is a second-year medical student at Chicago Medical School of Rosalind Franklin University of Science and Medicine.
Rollin (Terry) Fairbanks, MD, MS, EMT-P, is an assistant professor of Emergency Medicine at the University of Rochester (Rochester, NY), associate regional EMS medical director and REMAC chair.
Manish N. Shah, MD, MPH, is an associate professor of emergency medicine at the University of Rochester (Rochester, NY), chief of the Division of Prehospital Medicine, and the regional EMS medical director.