Scratching My Head

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Tenn. paramedic demoted after drug mistake

The story seem fairly clear cut, but the more I read, the more confused I got.

The patient had been hanging upside down for two days. I get that and understand that very serious complications can arise from that. The paramedic hung and gave the wrong medication. A doctor found that out and reported it. OK, that all makes sense to me.

Then the paramedic is demoted a couple of days later. That doesn’t make sense since there isn’t any indication in the story that he has a demonstrated history of making mistakes or of not following orders. I’m not making light of the mistake, since medication errors can be fatal. It just seems that this might be an over reaction to the mistake.

So, we know the patient’s injury,  what hospital to which he was taken, that a medical error occurred. When questioned about the details of the case and investigation, suddenly “patient privacy” kicks in.

Citing privacy laws, Wilkerson would not disclose what medication was administered to Davis. He also declined to release the internal investigation, based on the advice of Hamilton County Attorney Rheubin Taylor.

Wilkerson said the investigation did not take into account Davis’ condition after being given the incorrect medicine.

“It’s hard for us to know what is the effect of the medication and not be able to account for other stuff,” he said. “What was taken into account was what occurred.”

Is that last sentence even in English?

Or this one for that matter?

“Our goal is 100 percent success ratio and this is not the norm,” Wilkerson said.

Apparently management didn’t seem to be worried about the paramedics privacy since they released his work and disciplinary record.

I wonder if what is going on here is that the county is trying to protect itself against litigation. Closing the barn door after the horses are out, as it were.

On second thought, I’m not scratching my head, I’m banging it against a wall in frustration.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

11 COMMENTS

  1. Reading between the lines on this one sounds like he grabbed a premix lidocaine instead of a saline bag and gave a bolus. A mistake for sure, remediation and a letter in the file for sure, but we need to base his punishment on the patient’s response I think.
    Giving versed instead of morphine for pain control for example. It happens, if your service buys them in the same packaging and emotions are high on the scene, mistakes happen, we’re human. But if the mistake is caught early, as in this case, and the patient does not seem to be any worse because of it, why is the punishment so harsh?

    So many questions and a complete lack of understanding as to HIPAA. Ah, management…

    • I suppose that’s a possibility, although our premixed Lidocaine comes in 250cc bags so it would be odd for that mistake to happen. I was thinking along the lines of a adding Calcium or Bicarb to a liter bag to treat for compartment syndrome or crush injuries. Our meds come in what ever packaging the lowest bidder supplies (maybe yours is the same), so we always have to look carefully. Not that we should ever NOT look carefully because a lot of medications come in similar packages. We even have Calcium Gluconate and Sterile Water in similar vials with identically colored tops.

      I’m not making light of med errors in this or any other case, but the response here seems bizarre, to say the least.

  2. At my previous job in California (Ahhhhhh, feels good to say that), we carried 500cc pre-mix Lidocaine bags. They were stored in our med bag that was in a completely different place than our saline bags to avoid confusion. In fact, you actually had to break a seal to get one out. The problem with this story is the finger pointing on the companies part. Granted, all we know is what the media tells us, but I suspect this could have been a system problem. Yes, the paramedic screwed up, but he probably shares at least some of the blame with the system. What’s sad is that rather than use this incident as an opportunity to learn from and improve, they just put their employee on the chopping block.

    This kind of response doesn’t exactly encourage providers to report errors.

  3. Based on the few details presented, punishing errors goes against everything crew resource management and patient safety initiatives preach. I’m not making light of this either, but punishment is not going to prevent someone else from committing a similar error in the future. It will prevent someone from reporting it, though.

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