Thursday, November 10, 2005

QA/ A Hit

Interesting online article at about ambulance errors.

Ambulances Can Be Dangerous Places

Here's two excerpts:

In 1999, the Institute of Medicine published its report To Err Is Human, which estimated that up to 98,000 patients may die each year because of the mistakes of doctors, nurses, and other hospital workers. But few published studies have tried to quantify or even characterize the injuries to patients that take place before they reach the hospital. How frequent and how serious are the mistakes that take place in ambulances—and are there simple changes that could help prevent them?

Based on what we know about hospital-based medical error, ambulances may be one of the more dangerous places to be a patient. Studies have shown that medical error is more common when conditions are variable, like in the emergency room, than it is in other parts of the hospital. The problem likely has little to do with experience or skill. Instead it's about the lack of predictability: Doctors and nurses make more mistakes when they work under changing conditions. Think about that and compare the working conditions of paramedics and EMTs with an operating room. Before surgery, an entire staff is prepped with information about a patient's condition, medical history, and the anticipated plan of action. On an ambulance run, there is no plan. Paramedics and EMTs have to improvise as they encounter the obese, frail, terrified, combative, near-dead, stoned, violent, and newly born. And they have to deliver care in a cramped space with relatively few resources.


Thought-provoking article. At my monthly EMS meetings we often talk about the problems of quality assurance. As the number of patient runs increases, and as people charged with QA, whether ambulance service employees or hospital clinical care coordinators have increasing demands on their time, QA is suffering. I recently heard the laments of a fellow paramedic who works for another service complain that his service posted spread sheets detailing employee compliance with filling out billing information -- everything from getting the patient's signature to their next of kin's name, but nothing has been done to QA the front of the form or compliance with vital signs, ASA for chest pain. etc.


Only one call so far today. A 90-year-old man who woke up this morning and was unable to pee. "Don't get old," he said.


Get called for a back pain. Woman is in so much paid she is crying. Has a history of disc problems. Bent down and that was it. She can't get on the stretcher the pain is so great.

I get orders for morphine and give her a little at first. She does not like the flushing feeling at all. On the other hand, she still can't get on the stretcher. We are on scene for over an hour. Eventually she gets 10 milligrams of morphine. She weighs 260. I have to give her the morphine very very slowly and in very small increments. While I am giving her the drug, one of our EMT students, who I have great hopes for -- a tall young man and former star high school football player, has been holding the woman's hand as she squeezed his. He is watching me inject the IV lock, then all of a sudden like a big tree, he starts to lean, and he slowly, slowly falls over to the ground. "He'll be fine. He just fainted," I say to the onlookers. My partner attends to him, and in five minutes, after stripping off his jacket and outer shirt, he is back holding the woman's hand. Keep me in, coach, I'm ready to play. We are able to finally transport the woman now pain-free, although not quite singing The Farmer in the Dell. As for the fallen football hero, when we get back from the call, he signs up for a shift the next week. The kid can take a hit.


We do a chest pain.