Structured Inspection of Medications Carried and Stored by Emergency Medical Services Agencies Identifies Practices That May Lead to Medication Errors

From Prehospital Emergency Care:

Background. Medications are essential to emergency medical services (EMS) agencies when providing lifesaving care, but the EMS environment has challenges related to safe medication storage when compared with a hospital setting. We developed a structured process, based on common pharmacy practices, to review medications carried by EMS agencies to identify situations that may lead to medication error and to determine some best practices that may reduce potential errors and the risk of patient harm. Objective. To provide a descriptive account of EMS practices related to carrying and storing medications that have the potential for causing a medication administration error or patient harm. Methods. Using a structured process for inspection, an emergency medicine pharmacist and emergency physician(s) reviewed the medication carrying and storage practices of all nine advanced life support ambulance agencies within a five-county EMS region. Each medication carried and stored by the EMS agency was inspected for predetermined and spontaneously observed issues that could lead to medication error. These issues were documented and photographed. Two EMS medical directors reviewed each potential error for the risk of producing patient harm and assigned each to a category of high, moderate, or low risk. Because issues of temperature on EMS medications have been addressed elsewhere, this study concentrated on potential for EMS medication administration errors exclusive of storage temperatures. Results. When reviewing medications carried by the nine EMS agencies, 38 medication safety issues were identified (range 1 to 8 per EMS agency). Of these, 16 were considered to be high risk, 14 moderate risk, and eight low risk for patient harm. Examples of potential issues included carrying expired medications, container-labeling issues, different medications stored in look-alike vials or prefilled syringes in the same compartment, and carrying crystalloid solutions next to solutions premixed with a medication. When reviewing medications stored at the EMS agency stations, eight safety issues were identified (range from 0 to 4 per station), including five moderate-risk and three low-risk issues. No agency had any high-risk medication issues related to storage of medication stock in the station. Conclusion. We observed potential medication safety issues related to how medications are carried and stored at all nine EMS agencies in a five-county region. Understanding these issues may assist EMS agencies in reducing the potential for a medication error and risk of patient harm. More research is needed to determine whether following these suggested best practices for carrying medications on EMS vehicles actually reduces errors in medication administration by EMS providers or decreases patient harm.

Nitrous Oxide for Procedural Sedation

From (the consistently excellent) Emergency Medicine Literature of Note:

Why Aren’t You Using Nitrous Yet?

Another massive study reviewing adverse events encountered during procedural sedation – this time with nitrous oxide given in concentrations up to 70%.  It is odd that resistance is encountered regarding high concentrations of nitrous oxide – considering 30% O2 is still greater than the fraction of inspired oxygen on room air – but this, and other studies like it, should help allay any concerns.

Prehospital 12-lead ECGs & Detecting STEMIs

From JEMS:

Investigators from the University of Toronto, using the Toronto EMS system, sought to evaluate the effects of serial 12-leads in capturing more patients experiencing a STEMI. Over a one-year period, data on 325 patients experiencing STEMI identified in the prehospital setting were retrospectively analyzed. Summary statistics show that initial STEMI identification based on the first 12-lead ECG obtained was 84.6%, with cumulative totals of 93.8% on the second, and 100% on the third (or 9.2% and 6.2% increases respectively).

Investigators concluded that prehospital providers who perform a single 12-lead on patients experiencing chest pain or angina are at risk for a missed opportunity to identify STEMI in the field.