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Do Medical Storage Practices Relate to Medical Errors?


Review Of: Kupas D, Shayhorn A, Green P, et al. Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors. Prehosp Emerg Care. 2012;16(1):67–75

The Science
This is a prospective observational study of nine EMS agencies in a five-county region in Pennsylvania examining the risks associated with EMS medication storage practices. Two board-certified emergency medicine physicians conducted on-site checks of available ambulances and medication inventory storages. A standardized data collection form was used, which was developed in collaboration with a pharmacist knowledgeable of hospital and emergency department (ED) medication storage practices. Issues were classified as the following: high-risk, moderate-risk, and low-risk. Between the nine agencies, 38 medication issues were identified: 16 were high-risk; 14 were moderate-risk; and eight were low-risk. Issues ranged from expired medications to labeling issues and storing medication of similar dimensions and color in the same area. The investigators conclude more research is needed to assist EMS agencies, managers, and medical directors, in identifying methods to reduce risk and improve accountability.

Doc Wesley: Errors in healthcare account for more than 300,000 deaths per year in America. (1) This equals the number of patients who die from cardiac arrest. The difference is that errors are preventable. What’s more worrisome is how many errors go unreported, and the fact that the patient simply dies and no connection to the error is made. Although the number of deaths is staggering, the number of injuries is estimated to be in excess of 1.5 million.

So what potential does EMS have to cause injury to our patients from errors? No one really knows because error reporting in EMS is almost non-existent and there is little to no requirement to disclose such errors to patients. Regardless, we all know that medication errors are easy to make and some can be fatal.

This study is one of the first to critically examine how medications are carried on nine regional EMS agencies in Pennsylvania. What they found should cause every service to examine their own practice and policy, looking specifically for instances of the following:

• Carrying multiple different concentrations of medications and storing them in close proximity in the bag;
• Combining pre-mixed medicated IV solutions next to normal saline and other IV solutions;
• Carrying different drugs with similar packaging together in the same bag compartment; and
• Removing medications from their original packaging, which can promote failure to correctly identify them.
In the high-pace adrenaline-fueled environment of prehospital care, we simply can’t be too careful when it comes to medication administration to our patients.

Medic Marshall: First off, this is a great study, and the investigators should be lauded for their efforts. During the past several years, promoting a culture of safety in EMS has been an emerging trend—and now it’s even becoming a prominent topic of research, which is fantastic, because we need to understand the potential risks we’re inadvertently imposing on the public and our patients. Potential for medication administration errors is one of them. I believe this study does an excellent job at highlighting some of these issues. The Doc does a good job explaining the issues here, so I want to tackle a concept I think people have a hard time understanding: risk.

Risk is a tricky topic—I still have some difficulty comprehending and applying the concept to practical life. It comes up quite often in the literature I’ve come across and in the research I’ve conducted during the past few years. But what is it, and what does it entail? Well, from a research perspective (and a little simplified), you can look at risk as a probability of a certain outcome occurring given certain exposure(s).

To highlight an example of this concept, let’s look at texting and driving. A litany of research is out about distracted driving. One study from the National Highway Transportation Safety Agency in 2009 reported that texting and driving “creates a crash risk 23 times worse than driving while not distracted.” (2) This doesn’t mean texting while driving causes accidents—it means texting while driving raises the probability (or risk) of an accident compared to those that don’t involve texting and driving.

So how does this concept of risk relate to the study we’re reviewing? Well, every medication issue identified in this study contributes to the risk of a potential medication administration error. The more issues identified, the greater the probability that some type of event will occur.

As the authors of this study highlight, no standardization exists for EMS medication storage and administration practices. This creates a great deal of variability and lack of accountability on the provider and EMS agency. Furthermore, like the Doc pointed out, EMS doesn’t have an obligation to report medication errors. In my opinion, this is a tragedy. We need to work toward fostering a culture of safety and accountability—without fear of discipline or reprimands. EMS should be reporting its mistakes and using them as opportunities to learn and grow as an industry.

1. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. The National Academies Press: Washington, D.C., 2006.
2. National Highway Transportation Safety Administration. (n.d.) Distracted Driving: Facts and Stats: Texting and Driving. In NHTSA. Retrieved Oct. 16, 2012, from www.distraction.gov/content/get-the-facts/facts-and-statistics.html.

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.



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