Leslie Upledger Ray

Paramedic Self-Reported Medication Errors

Background. Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, andtreatment. Methods. A survey was given to paramedics in San Diego County. The survey tool was established on the basis of previous literature reviews andquestions developed with previous CQI data. Results. A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average of 25.4 hours and6.7 calls/shift. Thirty-two (9.1%) responding paramedics reported committing a medication error in the last 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), andwrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, andincorrect dosage given. Fatigue, training, andequipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% being reported by the base hospital radio nurse, 8.3% found upon chart review, and4.2% noted by paramedic during call but never reported. Conclusions. Nine percent of paramedics responding to an anonymous survey report medication errors in the last 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Adult foreign body airway obstruction in the prehospital setting.

Background. Although the treatment of foreign body airway obstruction in adults has been well studied, few data exist on the characterization of prehospital experiences. Objectives. To describe the frequency, etiologies, andtreatments of foreign body airway obstruction in adults in the prehospital setting andto discuss the relative efficacies of treatments andpresenting factors that predict overall patient outcome. Methods. A San Diego County prehospital database was retrospectively reviewed for all adult patients over a 17-month period with data extracted on demographic characteristics, incident outcome, patient disposition, item involved in obstruction, location of episode, initial vital signs, initial level of consciousness, pertinent medical history, treatments initiated by bystanders andparamedics, andresponse to those treatments. Results. During the study period, there were 513 cases of foreign body airway obstruction in adults. Of these, 17 (3.3%) died. The mean age was 65.0 years, with increasing age correlating with worse outcome. The item causing obstruction varied widely, with medications andmeat being the most common items. The Heimlich maneuver was the most commonly used intervention, with an 86.5% rate of patient improvement. Magill forceps proved useful for three cases refractory to the Heimlich maneuver. Presenting vital sign aberrations, particularly with respiratory rate, correlated with poorer patient outcome. Conclusions. Foreign body airway obstruction represents a true emergency in adults, with a 3.3% mortality rate in the current study. The Heimlich maneuver was used frequently andwith good success. Key words: paramedic; choking; adult; foreign body.

Pediatric Poisonings in Children Younger than Five Years Responded to by Paramedics

BACKGROUND Treatment of poisonings in children has been well studied, but few data are available on the various causes of the poisoning episodes in the pediatric population. OBJECTIVES To describe the incidence and demographics of accidental poisonings incurred by children<5 years old in the County of San Diego, California who accessed paramedics through the 9-1-1 system. METHODS Eight years of prehospital records for children<5 years of age were searched for poisoning cases. Detailed narrative information was abstracted to determine the circumstances surrounding the incident. RESULTS There were more than 40,000 paramedic transport calls for patients 5 years and younger over the study period; 996 (2.5%) of these calls had the chief complaint of poisoning. Of the calls classified as poisonings, 38% involved a 1-year-old and 35% involved a 2-year-old. Fifty-six percent of these poisonings involved either prescription or over-the-counter medications. An additional 16% were due to household cleaners. Eighty-eight percent of all calls were classified as mild in acuity, with 13% of poisoning calls for children under a year of age classified as moderate or acute; 50% of moderate or acute poisoning calls were to children 2 years of age. July and March were the months with the highest incidence of poisoning calls. The fewest calls were received on Saturdays and Sundays. CONCLUSIONS Children 1 year of age had the highest incidence of unintentional poisonings. Among all age groups, medications were the number one cause of unintentional poisonings. Other unintentional poisonings could be prevented if hazardous materials were out of reach of children; many of the cases in this study happened in front of the parent with the parent watching.

Impact of the San Diego county firestorm on emergency medical services.

BACKGROUND: In October 2003, San Diego County, California, USA, experienced the worst firestorm in recent history. During the firestorm, public health leaders implemented multiple initiatives to reduce its impact on community health using health updates and news briefings. This study assessed the impact of patients with fire-related complaints on the emergency medical services (EMS) system during and after the firestorm. METHODS: A retrospective review of a prehospital database was performed for all patients who were evaluated by advanced life support (ALS) ambulance personnel after calling the 9-1-1 emergency phone system for direct, fire-related complaints from 19 October 2003 through 30 November 2003 in San Diego County. The study location has an urban, suburban, rural, and remote resident population of approximately three million and covers 4,300 square miles (2,050 km2). The prehospital patient database was searched for all patients with a complaint that was related directly to the fires. Charts were abstracted for data, including demographics, medical issues, treatments, and disposition status. RESULTS: During the firestorm, fire consumed > 380,000 acres (> 938,980 hectares), including 2,454 residences and 785 outbuildings, and resulted in a total of 16 fatalities. Advanced life support providers evaluated 138 patients for fire-related complaints. The majority of calls were for acute respiratory complaints. Other complaints included burns, trauma associated with evacuation or firefighting, eye injuries, and dehydration. A total of 78% of the injuries were mild. Twenty percent of the victims were firefighters, most with respiratory complaints, eye injuries, or injuries related to trauma. A total of 76% of the patients were transported to the hospital, while 10% signed out against medical advice. CONCLUSION: Although the firestorm had the potential to significantly impact EMS, pre-emptive actions resulted in minimal impact to emergency departments and the prehospital system. However, during the event, there were a number of lessons learned that can be used in future events. Language: en

COMMUNITYTRIAL TODECREASEAMBULANCEDIVERSION OFPATIENTS ANDHOURS

the study site. Patients arriving by EMS had prehospital ECGs obtained, with the decision to activate the catheterization lab often made prior to patient arrival. Patients were grouped according to whether they presented during weekday working hours (0800 to 1800) or during off-hours (all other times). Catheterization lab personnel were typically on duty during business hours, but had to be called in during off-hours. Time intervals from emergency department arrival to balloon inflation were measured. Patients with nondiagnostic initial ECGs were excluded. Statistical analysis was performed using the Mann-Whitney U test. Results: A total of 142 AMI patients were taken for emergent angioplasty during the study period. Of these, 23 had nondiagnostic initial ECGs. Of the remaining 119 patients, 50 were treated during weekday business hours and 69 were treated during off-hours. The mean door to balloon time during business hours was 69 minutes (median 65 minutes, range 36–227 minutes). The mean door to balloon time during off-hours was 107 minutes (median 90 minutes, range 46–595 minutes). These differences are significant (p, 0.0000). Conclusion: The mean and median door to balloon times differ significantly between business hours and off-hours. Because these differences may impact outcome, it is imperative that EMS provide advance notification of arrival so that the cardiac catheterization lab can be readied for patient arrival. This need for advance notification is especially important during off hours.