Medication Mistakes and Demotions

A few days ago, EMS1 reported that a Tennessee paramedic had been demoted for administering an incorrect medication to a patient. I have mixed feelings about this and I’d like to know your thoughts.

My first thought is that we can’t race to judge if the discipline was warranted or appropriate in this specific circumstance. As always, in incidents like this, only a rare few people actually know the whole story. None of us can speak to the paramedics experience, his thought process, his history within the organization or his reputation. It is unlikely that any of us will ever know whether this was an isolated event or a problematic trend.

Having said that, I always have reservations about punitive responses to honest medical errors. I just think that they aren’t the right way to solve these types of problems. Human beings error. As long as humans carry out the work of medicine there will be errors. They are indeed inevitable.

Once we make peace with this idea, we can go about the real business of reducing errors to an acceptable minimum and always striving to reduce the number of occurrences and the harm done with each error. That’s easy for me to say. And it’s probably easy for a lot of folks to believe, until a paramedic makes a high profile error like this one and the family’s, facilities and media are clamoring for a response. Then discipline seems like a good idea.

Here’s the rub. Dicipline doesn’t seem to do anything to reduce or prevent the next error. In fact…discipline may make the problem worse.

It’s an interesting dilemma. I’d like to hear what you think.

Comments

  1. I live in the area and an somewhat familiar with the medic in the article. He’s a nice guy, maybe a little ADD, but a good medic otherwise. That said, one should always double check any drug they give a patient. It was clearly marked, so the mistake should have never happened.

  2. Like you said, mistakes happen; we are only human. Especially when you have a persons life on the line; I’m guilty of this, like any EMT or Paramedic who has experienced complicated calls. On the other hand, EMS has changed. Well, I shouldn’t say EMS has changed, but the world has changed. What once “happened in the ambulance stays in the ambulance” is now broadcast across YouTube and the rest of the internet in a matter of seconds. It has definitely changed the way EMS approaches patient care; it was made us way more cautious. The public expects medicine and EMS to be a miracle, but that is not always the case. People are shocked when they call 911 and don’t hear an ambulances sirens within seconds. When EMTs and Paramedics show up and have to be told what is going on, instead of seemingly already knowing like in the movies. EMS is entering another era, and this case is symbolic of it. Who knows what the future holds?

  3. I read a blog post about failure, responsibility, and transparency in the space industry immediately before this reading this post. An interesting coincidence…

    http://waynehale.wordpress.com/2011/09/20/the-school-of-hard-knocks/

    Wayne is retired from NASA now, but was in charge of the space shuttle program for a long time, and has some interesting insights.

  4. I don’t accept that errors, accidents, and injuries are inevitable. If they are inevitable I would prefer that we simply select who will get hurt.

    Adopt a zero accident attitude for the next patient or shift or day or month.

    If the only correction to this error was a demotion of the medic it only prevents him from making an error. The demotion doesn’t do anything to correct the system or prevent other medics from making the same error. The demotion also sends a message to the rest of the workforce that they are all on notice. If I worked there I would be looking for a new job where I was going to be set-up for success rather than monitored and punished for mistakes.

  5. Steve Whitehead says:

    @Greg You may not accept it and yet the theory of necessary fallibility prevails every time.

    http://www.ncbi.nlm.nih.gov/pubmed/9406111

    Error reduction and error prevention are noble and worthwhile efforts. But error elimination is not a reasonable goal. As evidenced by the fact that you’ve never seen or heard of an error free medical work environment.

    This isn’t all bad by the way. Errors happen to be one of the ways we learn and grow as human beings.

  6. I don’t agree he should have been demoted, just re-trained in the use of that particular medicine or review of when to use what meds.
    I also agree with Paul, the media mainly movies and tv shows give a false perception of what we in EMS really does on a daily basis what all we are capable or not capable of handling in the field. There are a few exceptions mainly on the Discovery networks.

  7. To punish anyone for making a mistake is ignorant. Even the hidebound field of nursing has awakened to this concept, and is beginning to understand that errors are not the “fault” only of the person who made the mistake. The Institute for Safe Medical Practices (www.ismp.org), started in 1975 in the Philadelphia area, understands this, and a look at their “About Us” page (http://ismp.org/about/default.asp) from their huge website is quite illuminating on this topic.
    In my opinion, Chief Wilkerson needs to read and learn, and then demote himself for his error.

  8. Off-topic, but I have to wonder what possessed anyone to leave Melvin Davis or any living creature hanging upside-down by one ankle for two days. What the hell is going on out there, good people? I hope he can afford a lawyer.

  9. I have to say that if you get your hand smacked for doing something wrong you do pay extra close attention while doing it again…at least for a while. Its like when you get a speeding ticket, you slow down for all of a week. But in an industry such as EMS where factors like high stress eviroments and sleep fatigue are common, I do not know how much good it does. I think the agency is just trying to save face. Possibly a better response would be mandated remedial training. In that case administratively you can show the problem was addressed and dealt with and if it happens again you know you have a problem.

  10. I find the whole culture of hiding your errors as a real hinderance to learning and growing in any job. Being a private pilot we have an option to report to NASA via a mailed report on something we did that broke one of the many thousands of reg’s we need to follow. If you file this report within 24 hours of the infraction it is more or less a “get out of jail card”, unless it is a criminal act (drinking, loss of life, etc). Too bad there is not (yet) such a reporting option for the medical world, people would be more open to admitting their errors if they knew they wouldn’t loose their job or position. I think this is even more pervasive in the entire medical field, the public has such high expectations, they never expect an error or death, litigation is their first response. We all need the option to learn from the errors made so that we all can become better.

Trackbacks

  1. […] Medication Mistakes and Demotions […]