Need to know
For #TeamEEAST Last updated: 02 May 2024 at 08:42
We have recently investigated an incident involving a patient with a complex medical history, who presented in status epilepticus and subsequently deteriorated into cardiac arrest.
During the review of the case, it was noted that the administration of Diazepam was not in-line with JRCALC guidelines.
There was no associated harm with the drug error, however, we were able to identify that the JRCALC guidance for Seizure Management gives a clear flow chart of treatment actions, whereas the Diazepam drug page is not as easy to follow.
The flow chart of treatment actions is available on the JRCALC app.
The Trust also issued a safety notice relating to the incident which contained the following:
Safety Notice – 29/03/22
Diazepam Administration
It has been identified that the JRCALC diazepam guideline for adults <70yrs can
be read ambiguously in emergency situations.
Please familiarise yourself with the attached flow chart or JRCALC link for seizure management and remember:
Two autonomous doses of diazepam can be given by a paramedic
Diazepam dosing schedule (for adults <70yrs):
10mg IV followed by 10mg IV (if required)
OR
20mg PR followed by 10mg IV/PR (if required)
Checking treatment regimes
If you are unsure about the dose/route of drug administration, please contact CAL/ emergency CAL for advice and or clarification. CCD is also available on CH202 to assist with enhanced care to scene, which may well be required to assist with the management of status epilepticus.
Pre-drug administration checking
It is vital that we follow a robust checking process prior to administration of medications, especially in high pressure situations, such as time critical presentations. It is not uncommon to see that in high stress situations, we may be tempted to cut corners with drug checking, in an effort to expedite drug administration. Drug checks are more important in this type of situation, as we are at higher risk of making errors.
Safety Notice – 18/07/2022
Checking and Administration of Medication
THE PROCESS SHOULD BE RESTARTED FOLLOWING AND DISRUPTIONS OR DISTRACTIONS DURING POINTS 1-4
Further guidance can be found here: Check, check and check again: administering drugs (eastamb.nhs.uk)
If you are interested, further reading can be found here Did-You-Know-High-Level-Medication-Errors.pdf (resolution.nhs.uk)
Human Factors
Pre-hospital emergency medicine is often practiced in a high stress, high performance and high-risk operational environment. Critical decisions are made, and actions taken with potentially limited information and resources. Poor performance can lead to harm, and in a small number of cases, the death of a patient. Multiple professionals with various skills and ‘ranks’ are involved, which can create challenges to communication or a perception of hierarchy. Co-ordinated activity within and between professionals is required and it is vital we all feel empowered to speak up and challenge a clinical decision or intervention if we are aware of an issue.
The Dirty Dozen
Error theory in clinical practice has been hypothesised to result from twelve key factors, which can exist independently, or as multiple contributory factors to an error. We should all be aware that working in the pre-hospital environment, our decision making is exposed to a number of these factors, which may impact on the accuracy of our decision making.
Factors such as a noisy or otherwise austere environment, high acuity or rare clinical presentations, lack of resources, working in flash teams etc, can all contribute to us making a drug administration error. We should be aware of these factors, and where possible manage them. One of the best mitigations to these factors, when considering drug errors, is following a thorough drug checking process with a suitable colleague.
The dirty dozen:
Bandwidth
Bandwidth is our ability to process information, a bit like the RAM of a computer. If we have too many windows open at the same time, the computer can slow down in processing time and eventually crash. Our ability to function cognitively is similar, and in trying to complete multiple tasks, or process complex information, we may have much reduced brain power to complete simple tasks, such as checking a drug dose or route of administration.
It is vitally important that we actively create bandwidth to check medication prior to administration. Generally, this can be achieved by actively taking the time to check a drug with a colleague, or by calling CAL if you are working alone in a complex situation.
Summary
Drug administration errors are a real risk in pre-hospital practice, for several reasons, some of which have been discussed above. It is essential that we all take the time to adequately check drugs prior to administration, which will greatly reduce the risk of an administration error.
Please also familiarise yourself with the JRCALC treatment flow chart for convulsion management and use the clinical app to check drug dosages. If you do not have access to the clinical app, please contact QI@eastamb.nhs.uk.
If you think you have made an error, please follow the duty of candour process and the report the error via Datix. If you would like to discuss any of the content within this bulletin, please contact your sector clinical lead in the first instance, either directly or via the team inbox clinical.leads@eastamb.nhs.uk.
Published 22nd July 2022