Recently, I was perusing my Facebook feed and stumbled upon a conversation regarding medication safety and administration.

I find the number of paramedics who stated it was OK to allow an EMT to prepare a medication during a cardiac arrest fairly surprising. Although the conversation was specific to cardiac arrests, I found myself wondering how many of those providers allow an EMT to prepare a medication during another critical event. And, what’s the impact on medication safety?

I politely shared my thoughts on the subject stating it was not appropriate for EMTs to prepare medications for administration that are outside their scope of practice. Those with opposing views began to comment with varying justifications.

Both the United States and Canada have identified the reduction of medication errors as a priority to improving patient safety. Medication errors increase during stressful situations.

Do we operate under stressful situations? Yes. We work on the side of highways at night with minimal lighting and excessive noise.

We do our best in each situation to focus on patient care, but also must maintain situational awareness and jump from protocol to protocol as each patient’s condition changes.

Research supports medication safety practices

A 2012 study also found medication errors are more common when there is extended transport time and when multiple medications are administered. Two other studies completed in 2006 and 2012 found a high number of medication errors specific to pediatric patients.

Conducted in Los Angeles County, the 2006 study found that providers improperly administered pediatric epinephrine 65.8% of the time.

The 2012 Michigan study found 35% of children received an incorrect dose even when the provider documented the patient’s weight, and similar to the LA County study, 60% of the epinephrine doses were incorrect.

Whenever there is a medication error it always goes back to the six rights of drug administration. The healthcare provider failed to address all six rights.

The six rights of drug administration have been the foundation of medication safety since the inception of emergency medical services. They include:

  1. Correct patient — Right patient
  2. Verify the proper medication and prescription — Right medication
  3. Check the form and dose of the medication — Right dose 
  4. Verify the route of the medication — Right route
  5. Check the expiration date and condition — Right time
  6. Document your actions and the patient’s response — Right documentation

There also is an initiative to add a seventh right — the right to refuse. Any time we administer a medication informed consent is a must.

The risks associated with a medication may be too much for the patient and he or she has the right to refuse a single medication or all of the medications we wish to administer.

Due to this, experts recommend using a formal system every time we determine that patient care requires medication.

The MACC system

Sedgewick County EMS in Kansas developed the Medication Administration Cross-Check (MACC), formal script used prior to every medication administration.

  • Provider 1 calculates the drug dose and draws it up. They then must stop and say out loud, “Med check.”
  • Provider 2 must then confirm by stating, “Ready.”
  • Then, Provider 1 states the drug name, dose, route, rate and reason for administering.
  • Provider 2 considers this information and, if they have no concerns, they ask, “Contraindications?”
  • Provider 1 reconsiders possible contraindications. If none are present, they reply, “No contraindications.”
  • Then, Provider 2 inquires, “Volume?”
  • Provider 1 shows the vial and states the drug concentration and volume to be administered.
  • Provider 2 considers this and, when satisfied, states it is safe to administer the drug by saying, “Sounds good. Give it.”

Does the MACC have any issues associated with it? Yes, it has proven time consuming and cumbersome.

Providers may choose to rush through the checks in critical events. Is this going to be an issue all the time? No. As we all know, a majority of our calls are minor in nature and the family did not know what to do, so they called for assistance.

My biggest concern with this system relates to the conversation about EMTs preparing advanced life support medications for his or her paramedic.

Effective methods for medication safety

Parroting the medication orders given over telemetry, using decision aides, labeling syringes and high-fidelity simulation are some of the methods that have proven effective. Parroting has been the expectation for decades and yet some crews fail to do it.

The physician originating the order or the RN charged with relaying the information should insist the pre-hospital provider parrot the order back. Decision aides are essential, especially with pediatric patients.

While Broselow tape has remained in use for many years, experts have now moved it into a category where it doesn’t get used as a stand-alone resuscitation tool.

The Broselow lacks accuracy in regard to weight and drug dosing.

The Handtevy system has become more popular because of its reliability. Online resources also are recommended, but I am not using my phone on scene for two reasons:

  1. I’m not touching my personal phone while wearing dirty gloves.
  2. It can look unprofessional since the family may not be aware I am retrieving essential information, instead of checking Facebook.

Labeling syringes is not something we normally need to do, but occasionally we draw medication into an unlabeled syringe.

Take a moment and label it. The American Nurses Association surveyed its members on this topic. They found that 68% agreed labeling syringes would reduce errors, but only 33% stated they label syringes every time.

High-fidelity simulation is becoming more common. It allows us to place students and employees in stressful situations in a secure, safe environment. Our industry — both the public and private sectors — need to commit to investing in high-fidelity mannequins regardless of the cost.

This has been a standard in medicine and nursing for years. It’s time we catch up.

Discuss this topic with me in ALS Lesson 18 — Includes OB Emergencies and Medication Administration, CRM.