In the prehospital environment, medication errors are

a constant threat to patient safety. Several unique factors

make medication errors more likely in the prehospital environment

compared to a hospital setting:

• Chaotic scene where bystanders or family may distract responders.

• The patient may rapidly decompensate, requiring immediate care.

• Resources may be limited: Other EMTs or paramedics may be busy

performing necessary procedures or managing the scene.

• Medications are not distributed by a Pyxis®-style system, so a look-

alike vial may be grabbed instead of the intended medication.

• Medication order and dose verification is not confirmed by a

computer charting program. High risk medications (insulin, tPA, or blood products, for example) require

two nurses to electronically-verify the dose and medication in the hospital setting, but this type of

safeguard is not in place for EMS.

• Certain emergent drug dosages, indications, and contraindications may need to be memorized. Without

reviewing the protocols during down time at the station or while posting, your recollection of the dose

and other information may be inaccurate.

Since medication errors are more likely to occur in the prehospital setting, we need to be more diligent in

checking, double-checking, and preventing these errors in the first place. Most medication errors are

PREVENTABLE.

HOW COMMON ARE MEDICATION ERRORS IN THE PREHOSPITAL SETTING?

San Diego county paramedics were asked to participate in an anonymous survey about medication errors over a 12

month period of time.1 The researchers received 352 surveys, with the paramedics averaging 8.5 years of field

experience. The average call volume was 6.7 calls per 24-hour shift.

Over 9% of the respondents reported known medication errors. Surprisingly, fatigue, training, and equipment set

up was not listed as contributing factors. Instead, they reported a failure to triple-check medication name/dose,

infrequent use of the medication itself, and dosage/route errors.

Medication Safety for EMS A quick cup of protocol-driven education for UMC EMS

What is a Medication Error?

“A medication error is any

preventable event that may cause

or lead to inappropriate

medication use or patient harm

while the medication is in the

control of the health care

professional, patient, or

consumer.”

- National Coordinating Council

for Medication Error Reporting

and Prevention (NCCMERP)

1 Vilke GM, Tornabene SV, Stepanski B, et al. Paramedic self-reported medication errors. Prehosp Emerg Care. 2006;10(4):457-462.

It’s not just the adult patients who are affected by medication errors.

A retrospective analysis of 360 prehospital medications administered to pediatric patients found medication errors

in 35% of all cases.2 Excessively high doses of intravenous epinephrine were common for pediatric cardiac arrest.3

A major contributor to the error was listing both milliliters per kilogram (mL/kg)

and milligrams per kilogram (mg/kg) doses for epinephrine in cardiac arrest

protocols.

Weight estimation was also a concern in this last study. A large number of the

pediatric patients’ weight for drug dose calculations was visually-estimated by the

EMS crew, but not measured using a Broselow-Luten pediatric tape.3

THE RIGHTS OF MEDICATION ADMINISTRATION

In the perfect world, the “rights” of medication administration would be ingrained from the earliest EMT class and

constantly practiced throughout the paramedic level to avoid preventable medication errors. However, this ideal

education and consistent reinforcement does not always happen. In addition, the nature of the EMS setting itself

modifies these rights. For example, if you are caring for one patient in the ambulance, do you really need to

confirm the patient’s name and date of birth before giving a medication? In the hospital setting, this is an absolute

necessity since an emergency department nurse is usually caring for three or more patients at the same time.

Stepping through the basic six rights of medication administration is the BEST way to prevent medication errors.

Six Basic Rights of Medication Administration

Right Patient

Right Medication

Right Dose

Right Route

Right Time

Right Reason

2 Kaufmann J, Laschat M, Wappler F. Medication errors in pediatric emergencies. Dtsch Arztebl Int. 2012;109(38):609-616.

3 Hoyle JD, Davis AT, Putman KK, et al. Medication dosing errors in pediatric patients treated by emergency medical services.

Prehosp Emerg Care. 2012;16:59–66.

RIGHT PATIENT

EMS usually has only one patient at a time. There’s no

armbands or other identifiers to double-check compared to

a hospital setting. However, since we have some autonomy

in drug selection, we need to ask: Is the medication

considered safe enough to use with the patient’s medical

history, signs/symptoms, your field diagnosis, and the

patient’s home medication use?

Does your patient have liver disease or instead spends three

days a week at dialysis? Does his chest pain, appearance,

ECG, and recent events suggest an aortic dissection instead

of a STEMI? Any atrioventricular blocks on the ECG? These

factors and others need to be considered before giving any medication.

For EMS, we have to ask: Is this the RIGHT PATIENT for the medication?

RIGHT MEDICATION

We work in dark or crowded places with lots of distractions and

plenty of things that need to be done. We sometimes find

ourselves in a hurry to keep our patient alive.

However, we still need to remain diligent in checking the name of

the medication, the concentration, and the expiration date for

every patient, every time.

Don’t assume the crew who completed drug pull at the beginning of the month caught every expiring medication.

And don’t assume the clear fluid in the syringe is the correct medication and dose. Always read the vial for

yourself and confirm the drug name and dose with the person who drew up the medication. Even vial cap colors

can be different one month to the next. The purple epinephrine 1:000 cap may be blue next year.

“I have diabetes, high

blood pressure, and the

doctor said I have some

sort of heart problem.

Is this medication safe

for me?”

Which of the medications shown below is amiodarone, ondansetron (Zofran), diphenhydramine (Benadryl), and

adenosine?

The answer from left to right: Adenosine, diphenhydramine, ondansetron, and amiodarone.

RIGHT DOSE

The right dose is just as important as any other right, but this is

where EMS usually makes the most mistakes. Someone else may

be drawing up your medications while you manage your patient, but

do you really know how much medication is in that syringe?

Here’s a scenario to consider: You’re about to intubate a patient and

your partner hands you an unlabeled, drawn-up syringe shown to

the right. “Ketamine” he says, and then turns away to draw up more

drugs. What if he accidentally handed you the paralytic instead?

Now considering the syringe in the photo to the right, did he just

hand you the entire vial’s worth of ketamine, or is this the patient’s

weight based dose diluted in normal saline?

This medication error was avoidable. The person drawing up the medication should have told his partner how

much medication was in the syringe, and the person giving the medication should have confirmed the vial, the

drug in the syringe, and amount (milligrams or micrograms) before proceeding. The best practice would to only

fill the syringe with the exact amount needed in case the person administering the medication is bumped or

there’s any confusion about the dose. If it’s diluted, say so.

Keep in mind that with nationwide drug shortages, the

concentration (mg per mL) or the volume of medication in a

vial could change without notice.

The two dopamine bags shown to the right are the exact

same size, are printed with the same colored ink, and

otherwise appear identical except for the concentration

listed on the front. Both bags were found on in the same

ambulance cabinet back when the 800 mcg/mL

concentration dopamine was still in our protocol:

• Bag on the left: 200 mg/250 mL (800 mcg per mL)

• Bag on the right: 800 mg/250 mL (3200 mcg per mL)

The higher concentration bag on the right would have given 400% more dopamine than needed if the 200 mg/250

mL drug calculations were used by a crew. Always check your medication concentrations “just in case”.

RIGHT ROUTE

The acceptable routes are in the protocols for a reason. Some drugs will be less or more effective depending on

the route, and even some adverse effects may be route-dependent. Administration duration (rapid IV push versus

a drip) influences how well the medication works, or if it even works at all. For example, a slow IV push of

adenosine will not be effective, and conversely, a rapid push of ketamine can cause transient apnea or vomiting.

Some medications work very quickly via the intramuscular (IM) route, including midazolam (Versed) and ketamine.

On the other hand, Lorazepam (Ativan) has a very slow onset of action if given intramuscularly. This is why

intranasal or intramuscular midazolam should be administered to an actively seizing patient who has no IV access.

Lorazepam (Ativan) would take too long. Even though lorazepam has a longer duration of action, you need to stop

the seizure activity as soon as possible to prevent continued hypoxia and tissue injury while you wait for this drug

to take effect. If the patient then seizes again in your ambulance and now has an IV in place, Ativan may be

appropriate to use since the seizure just started again and the patient has been oxygenated, etc.

RIGHT TIME

In EMS, we administer medications because they are needed now. Patients admitted to the hospital will have

scheduled and as-needed (PRN) medication orders; not something that EMS is concerned about in the prehospital

setting.

However, the time component of the medication rights asks the

paramedic: Are you waiting long enough between repeat doses?

Every drug has a unique peak time and elimination half-life, and

even drug accumulations need to be kept in mind.

For example: Should fentanyl be repeated every 5 minutes, 10

minutes, or should the patient wait 20 minutes?

Another example: For chest pain patients, sublingual nitroglycerin

has a peak effect at about 5 minutes, but it’s elimination half-life

ranges from 1 to 4 minutes. Its effectiveness may drop rapidly.

This is one reason nitroglycerin is repeated every 5 minutes until the chest pain resolves or blood pressure drops

below an acceptable threshold.

RIGHT REASON

This can be the most difficult and yet important “right” for EMS simply due to our freedom with patient treatment

decisions. We need to understand our medications, the effect on the body, and make educated decisions. Some of

the examples below follow the “right reason” component:

Why is enalapril contraindicated in pregnant patients?

Should ondansetron (Zofran) be given to a hypotensive patient with vomiting?

If the patient has a STEMI but fell to the floor with a severe head injury, is aspirin still safe to give?

Why shouldn’t we give more than one DuoNeb (albuterol + ipratropium) to a CHF patient?

Can ketorolac be given to a pregnant patient in pain?

If an LVAD patient has chest pain, should he receive nitroglycerin?

Click on the film reel image above to stream a YouTube video that shows that it only takes a few seconds to avoid a

medication error.

A best practice: One responder selects the medication, shows the vial to another responder to confirm the name,

expiration date, appearance (is it an abnormal color?), and drug concentration. Only the amount needed for the

patient is drawn up into the syringe; the remaining amount is left in the vial. If several medications will be needed

or administration will be delayed, clearly label the syringe(s) with the name and amount of medication drawn

up. Which syringe has 200 mg of ketamine and which one has 100 mg of rocuronium? A flagged strip of silk tape

could work as a quick label for the syringe.

Both responders should agree on the indication for the medication, verify no known contraindications, confirm the

name and amount of medication in the syringe, and agree to the expected speed of administration. Always

confirm with the patient that no allergies exist for that specific medication, and educate on the purpose/expected

result whenever possible.

CONTACTING MEDICAL CONTROL BY RADIO FOR A MEDICATION REQUEST

Radio reception and transmission can sometimes be a problem, and it may be difficult to understand orders

requested to or given by medical control. Always “read back” any order for medication over the radio and receive

confirmation that the order is correct from the other end. Do not give a medication if any part of the dosage or

administration is unclear.

Example of confirming orders given by medical control:

“Confirming an order for 50 micrograms of fentanyl slow IV push for continued pain, per doctor

Treeawwgee?”

To earn credit for this continuing education, log into your CE account and complete the quiz entitled, “Refresher:

Medication Safety for EMS”. If you have any questions about the education, please contact your Senior FTO or

Training Chief.