EMS Medication Errors: Prevention

• Legal considerations and documentation are critical in prehospital care
• EMS providers must operate within their scope of practice
• EMS duties include accurate documentation and following protocols to minimize liability, and improve patient care

Medication Errors

• A medication error is a preventable event leading to inappropriate medication use or patient harm
• Errors can occur at any stage like prescription, administration, and monitoring

Common Causes of Medication Errors

• Miscommunication includes poor handwriting, verbal orders, or similar drug names
• Calculation errors arise from incorrect dosages due to improper conversions
• Failure to check allergies or interactions occurs when administering drugs without reviewing the patient’s history
• Fatigue and distraction can cause overworked EMS providers to make critical mistakes
• Improper storage and labeling of medications can lead to administration errors

Prevention Strategies for Medication Errors

• Follow the Six Rights of Medication Administration
• Right patient
• Right drug
• Right dose
• Right route
• Right time
• Right documentation
• Use checklists and standardized protocols
• Utilize crew resource management (CRM) techniques to enhance communication
• Double-check calculations and verify drug concentrations
• Maintain continuing education on pharmacology and medication safety

Documentation

• Proper documentation ensures continuity of care
• Documentation also ensures legal protection and accurate records for billing and quality improvement

Key Components of Documentation

• Patient information: name, age, sex, weight, allergies, and medical history
• Assessment findings: vital signs, chief complaint, physical exam, and any pre-existing conditions
• Interventions and medications administered: drug name, dose, route, time, and patient's response
• Communication: report details to receiving facilities and medical control
• Signatures: obtain patient or legal guardian signatures when possible

Common Documentation Errors

• Omissions: missing vital details such as drug dosages and routes
• Subjective language: using opinion-based notes instead of factual descriptions
• Illegibility: poor handwriting leading to misinterpretations
• Late entries: documenting long after an event raises legal concerns

Legal Aspects of Documentation

• If it's not documented, it didn't happen, and poorly documented reports can be detrimental in legal cases
• Electronic patient care reports (ePCRs) improve accuracy and legibility

Refusals of Care

• A patient refusal occurs when a competent adult declines treatment or transport against medical advice (AMA)

Legal Considerations for Refusals

• EMS personnel must ensure the patient has decision-making capacity, such as not being intoxicated, unconscious, or having an altered mental status
• The informed refusal process requires EMS to explain the proposed treatment and its benefits, potential risks of refusing care, alternative options, and the ability to call back for help if needed

Proper Documentation for Refusals

• Assess and document the patient’s mental status
• Explain risks of refusal
• Have patient sign a refusal form
• Obtain witness signatures from another EMS provider or law enforcement
• Offer transport multiple times and document each attempt
• EMS providers may need involuntary transport under local laws if a patient lacks decision-making capacity, due to altered mental status or suicidal intent

Operational Considerations

• EMS providers operate under standing orders and online medical control to guide medication administration
• Variations exist by state and agency, so understand local standard operating procedures (SOPs)

Liability and Negligence

• Negligence occurs when an EMS provider fails to act within their training and harms a patient
• Negligence requires: duty to act, breach of duty, injury resulting from the breach, and causation, where the breach caused the injury
• Good Samaritan Laws protect providers acting in good faith but do not excuse gross negligence

Handling High-Stress Situations

• Follow crew resource management (CRM) techniques to maintain clear roles
• Use closed-loop communication to confirm verbal orders
• Regularly conduct post-run reviews to assess performance and errors

Scope of Practice

• The scope of practice defines what medications and interventions EMS providers can legally perform based on their certification level

Allowed Medication Administration by Certification Level

• EMT (Basic): oxygen, epinephrine (auto-injector), glucose, naloxone (nasal), aspirin, nitroglycerin (assisted)
• AEMT: IV fluids, some IV medications, nebulized medications.
• Paramedic: full advanced life support (ALS) drug administration, including intubation medications and controlled substances

Deviation from Scope

• Administering a drug outside the scope without medical control approval is illegal and unethical
• Providers must stay up to date with state regulations and protocols due to regional variances