Ian German EMT-P, Medication Administration Cross Check (MACC) (1/24/25)

Welcome, Everybody. It is January 24th, it's Friday, and we're very excited to have.

A local paramedic who's a really amazing guy, had known him for a long time, and he's doing some things that all of us need to hear. And he did me the favor a few months ago, and he actually gave a version of this talk to some friends in South Carolina. The other special thing is that what he's talking about today is something that was developed out of Wichita. Sabina Braithwaite, who everyone knows is an EMS medical director, and Paul Masaki, who's on the EMS leadership there in Wichita, and they have published on this topic. And then we have folks like Ian who have taken the topic and are now trying to get it out to the masses, locally, regionally, just to help each other out. And fascinatingly, many of you may have seen what just came out on the news wires yesterday, which was apparently there was a paramedic who has been charged criminally for a medication error. So it's incredible what's going on. This topic is very, very important. And again, Paul and Sabina, thank you for joining. And Ian, I'm going to give you the rings. Take it away, my friend. Thank you so much for coming on the floor to EMS webinar.

Absolutely. Thank you, Dr. Anteby. You guys can see my screen and hear me. Everything's good.

Perfect.

Perfect. Awesome. All right, so thank you so much. I appreciate being here. Dr. Antebe, Dr. Pepe Tanner. I mean, honestly, I see you on here all the time, so it's cool to actually get a part of this. I've got 15 years in EMS and fire. I was the lead instructor for an outstanding paramedic program, training captain for about four years. And I focused on ems and I was on a competition team, like a nerd for the ALS competition. So I really love ems, and I bring that up because I hadn't ever one time considered the process in which I administered medications on the job. We just kind of did what we did, and it never occurred to me the impetus of how we got here was a few of our peers trusted us, and it told us about some of their experiences, and they helped us recognize a blind spot that had developed over time. So hopefully my goal today is to inspire you to survey your own systems and see where you have the same opportunities for improvement. I had absolutely no idea that these people would be here. This was just part of this. But Paul Massasi and Sabina Braithwaite were phenomenal. These are the folks that created this whole thing, they implemented it, they tested it, and they were incredibly gracious with their time. They shared all of their info with me, and they're just genuinely kind people. So everything that's here today started off with them just being kind enough to meet with us. So thank you so much. So this is kind of recent. This was in Newport, Kentucky. This was in 2022, and the lawsuit was in 23. In February of 22, Newport Fire and Rescue were dispatched to what you see in the picture, the Ovation Theater, for a fall with injury. They had one patient who had fallen and struck her head, had a laceration. They transported her for the laceration and for concern of a closed head injury. And almost immediately when they got into the apparatus, the patient stated that she felt nauseous and like she was going to pass out. This particular patient also happened to be a medical professional. She was a pediatric ER nurse, and she requested Zofran. So they agreed with that. One paramedic went ahead and grabbed the zo. Grab the medication syringe, pulled it up, pulled up 1cc, gave it over to the second paramedic, and he administered it through the IV. At some point after that, they realized that instead of pulling Zofran, they had accidentally pulled epinephrine 1:1000 and administered 1mL of that. I. To be fair, they did the right thing. They informed the patient, they told the hospital, they told their system, they monitored the patient. But a year later, lawsuits started showing up in the news. And there's a couple of things from her attorney that seemed pertinent here. One of the things they talked about was that neither medic looked at the writing on the vial to verify the medication, nor did they verbalize what medication had been drawn, handed off, or subsequently administered in the iv. These protocols were disregarded in their entirety by both medics as a direct result of the defendant's negligence, Gross negligence, wanton and reckless conduct, which sounds horrible. The plaintiff suffered what they're calling in this article, a medication induced MI with heart damage that's gonna be permanent. And experts say she's taken 10 years off her life, which I don't know how you can figure that out, but that sounds horrible. When we see things like this, we try to find the utility in them. There was already a mistake made. So how can we learn from and make sure that we don't do the same thing? So we started off with just wondering, okay, Zofran, what does this look like for us? We generally get the same Zofran almost all the time. It's a green vial with green writing and top on there, 4mg and 2mls. Every once in a while we get one different, one pre filled syringe that's almost exactly the same. But out of curiosity, I did a Google search and I did images just to see how many different ones there are. And what I found was pretty much every color combination you could possibly think of for the same medication. And then when I started looking at these and I see the ones that are kind of purplish pink and I see the ones that are kind of a blue and a purple, and I do the same thing for epinephrine, I can see how this can happen. I can see exactly how this could happen. Especially if you didn't have a system in place. There are a tremendous amount of medications out there right now that look almost identical. And with supply and chain issues and medication shortages, I think it's reasonable to expect that every agency is going to get meds, that they're unfamiliar with the packaging. So one of my chiefs asked, reached out to me and asked me to talk to our neighboring agencies and find out what they were doing for medication administration. So I called a fair amount of agencies. I called people from Miami Dade through Palm beach county and I wanted to know what is in your policy and protocol? What do you go through? And really the responses were the same as ours. They didn't really have anything. They made some assumptions what they thought was going on, but nothing that was actually in writing. The only feedback that I got was that some people assume they use the five rights. And I think it's bold to think that every crew is out there methodically banging out the five rights for every medication administration. To be honest with you, I don't even know what they are anymore because when I went to school it was the five rights. And I think when I left, we put in a sixth one. And then as time went on, they became more. And as we're going through this, the last one I saw was the 16 rights of medication administration. One of the things that I learned from Paul and Sabina was that a big flaw in these that they're typically done independently and you're depending on the person that's making the mistake to catch the mistake and fix that. And that's not highly likely to happen. So when we saw the Mac, we were super excited about it. The medication administration cross check is a two person verbal and really visual procedure and it deals with preparation, validation and confirmation of your administered medications. Essentially, Provider 1 does the skills Provider 2 does all the authorizations. If there's any interruption, they make sure that they figure out what happened and that they don't move on until everybody's in agreeance. It's got error traps built into it like volume and concentration, verification, and it's brief. It takes about 15 to 20 seconds to do. It doesn't take much time at all. This is the way it's pretty much laid out. They use clear, unambiguous language. So providerone is going to use the same term. We decided to go with medcheck every single time. Provider 2 then engages with the same idea, clear, unambiguous language, with the word ready. He's not going to say sure or go ahead. He wants to let the first provider know that they are both locked into this process. From there, provider one just says what he's going to do. I'm going to give 100 micrograms of fentanyl IV, slow push for pain. If Provider 2 agrees with that, he'll say contraindications. He'll ask his first question. If he doesn't, he'll resolve this before they go on. When it goes to contraindications, the three that they list in there are allergies, vital signs, and the medication being expired. But this is also an opportunity for provider one and for provider two to share information. Sometimes one person knows about something on a call the other person hasn't heard. And so if provider one doesn't know a contraindication is there or a relative contraindication, Provider 2 can now fill them in. But as long as there's no contraindications, they can keep moving through. And then Provider 2 will ask about volume because they told me they found a lot of their errors in this area. So he asked for volume. And provider one shows the syringe in the vial, talks about what the concentration is and how much they've drawn up, and basically gets a verbal and a visual verification. As long as all that's good, Provider 2 then gives the confirmation to go ahead and give the medication.

It's simple. Provider two has to remember to ask two questions. Provider one just has to do what they intend to do. You have the medications that can't be given without the completion of the cross check. So you're inserting another person as a barrier to that error for coming to the patient. And it creates pause points, which is phenomenal because a lot of times we're dealing with really stressful situations, and it's nice to have a way to sort of get back in Check. So we're decreasing medication errors, we're improving teamwork and communication, and we're giving a uniform medication administration for practices, a consistent one. One of the other things that I thought was really amazing too was it's in the textbooks. So this is from a class that I teach. This is the Nancy Caroline book, and it's literally in their pharmacology section. I don't have the Brady book, but I'm told it's in that as well. So it's being taught to students as they're coming out. It's been out there since 2013, at least from the presentations. It's just not being picked up on for some reason. And I think it's a tremendous missed opportunity.

This is some of their data, so they're here, so you can always ask them too. But they did a 54 month, 27 month pre Mac and 27 month post Mac study with their medication errors. And what they found I thought was pretty amazing. Now, number one, I had no idea about Sedgwick and I didn't know if they were busy or not. And they run a lot of calls. So they had a ton of Data. In that 54 months, they gave about 73,500 medication doses. They actually had an increase in their medication doses post macular implementation of 12.9%. But even with that increase, their error count went down by 43%. And that's across the board for medications. That's a pretty phenomenal number.

Now, if you're like our system, we track some medications better than others. They're not all tracked equally. Controlled substances are much, much better managed. So if we give EPI or Zofran, to be honest with you, we don't tie it back to the call and make sure that the dosage was correct. But with, with controlled substances, we need to see the waste, we need to tie it back. So those numbers are really interesting. And they had those. Their fentanyl doses went up post Mac implementation by 54%. But even with that increase in the amount of fentanyl, and you can see the numbers are huge, they gave 4300 doses post Mac implementation. Their error rate went down by 71%. So that's pretty phenomenal. So you have a tool that works, the cross check works as long as you actually employ it. And that's what I didn't understand. So when we go through this today, I want you to just think about a couple things. And that is, in your system, how are medications being administered by your agency? Whether you are A medical director or an EMS chief or you're one of the people in the field, you have an expectation of what is happening out there. But do you know that that's what it actually is? And if that is what your expectation is, if it is supposed to be happening, where is that information located? Do you have it in a policy? Is it written down in a protocol or a guideline? Do you have it as a verbal reference? Like one of the departments I talked to said that in their recruit camp they verbally tell them and they pass it down that way. Is it expected? Do you say you went to paramedic school and you should know how to do a medication check? And if that's the case, then what else is expected? Because when I look into the procedure sections of protocols, I see how to put on electrodes and how to start an IV and a lot of things that are less dangerous than medication errors. So when we became aware of the errors and I spoke with the agencies and I saw that there was really nothing in writing, I didn't really understand what the disconnect was. I wanted to know why they didn't feel an urgency and why we don't really realize a lot of the benefits that the MAT can be to us. And I pretty much looked at these five insufficient medication data and accountability, a lack of standardization, stressful environments, cognitive overload, and then some of the cultural barriers that we have in fire and EMS to reporting and improvement. I want to talk about those a little bit right now. The first one, insufficient medication data and accountability. I tried to find information on pre hospital medication errors and there's not a lot out there. A lot of this stuff is actually behind paywalls. And anytime I went out to an author and I asked for it, I was able to get it. But even behind paywalls there wasn't much. I actually talked to a guy from Australia that had a really good, a lot of good information, but still not a lot out there. And when we look at our controlled substances, sure we're tracking those, but when we're looking at other things like calcium dextrose, zofran, there aren't systems in place to account for those meds, nor are we really tracking any pertinent data, like what equipment was used. And what I mean by that is if I go to my EMS captain, I say I need to replace my epinephrine and I need a 10cc syringe. At that point there should be a 10cc syringe. Why would you need that? And maybe that brings something up, but for the most part, we can just go and restock our equipment and nothing is really tied back. So I wanted to find something that would be hopefully around the same realm, or at least give us some kind of data. And I decided that we would look at hospital numbers because they're not the same as us, but they kind of have the same thing. I'm going to use a transitive property that is completely unscientific and just assume that if it's happening there, that it's happening with us as well. When I looked at hospital data, for the most part, I saw that for every 100.