**6. Medication safety**

The five "rights" of medication safety, "right medication, right dose, right patient, right route, and right time" are ingrained in the foundation of every pharmacological safety discussion, yet most medication errors stem from one of these five "rights" being wrong. Medication errors are made even by the most careful and experienced clinicians; therefore, a system of safety checks should be established. Medication errors are rarely simple and typically are complex system failures. Creating a culture of safety around medications can be challenging due to many reasons, such as preconceived notions or workplace rumors. Recently, a medication error made national headlines that resulted in a nurse being charged with and found guilty of criminally negligent homicide [22]. Critics of this decision have all called this action a step back regarding patient safety [23]. Agencies should maintain a comprehensive medication safety policy that encourages reports of events and near-hit events and allows for a root cause analysis to make

changes to the system to prevent a recurrence. Outlined below are some ideas and concepts that can be utilized to enhance patient safety when it comes to medication errors.

#### **6.1 Medication cross-checks**

Medication cross-checks, or having a second qualified professional verbally verify that the appropriate medication and dose have been selected for the patient's size and condition, have been proven to be effective in preventing most medication errors [24]. During a 54-month period, these authors showed that implementing the system shown in reduced monthly errors from a rate of 0.19 to 0.09%. As opposed to other steps to ensure patient safety, this one is unique as it requires no up-front costs.

Despite the known benefit of cross-checks, they are not always utilized due to high-stress situations, varying levels of partner certifications, the delay when crosschecks are needed for multiple medications, and in administration of medications to pediatric patients. Creating this kind of culture of safety can also be difficult because of stigmas associated with patient safety, which serves as another barrier for implementation of these kinds of systems.

#### **6.2 Pediatric medication safety considerations**

In addition to cross-checks, easy-to-read medication aids or checklists, which include indications, contraindications, dosage and administration amount, and route of delivery, could serve as a protective layer against medication errors. These medication aids are especially important in the case of pediatric patients, as weight-based dosing in kilograms is the standard of care and errors in dose calculations are common. According to a position paper released by the NAEMSP in 2020, all pediatric medication aids should list the volumetric amount of a weight-based dose to be given instead of a mass-based amount [25]. For example, a chart referencing pediatric acetaminophen dosing based on the standard concentration of 160mg/5 mL would list that a child weighing 11 kg would receive 5mL of acetaminophen rather than 160 mg. Any changes in formulary concentration should be immediately communicated and medication aids revised to reflect such changes as soon as possible. Another step to take is requiring all weights entered in the ePCR to be in kilograms and not pounds [25]. This is a simple standard to adopt but seeks to eliminate any confusion between pounds and kilograms in the management of patients.

#### **6.3 Medication storage**

Safe medication storage is vital to patient safety, and careful consideration must be taken when selecting medications for EMS use and in what arrangement they are kept. When selecting medications, there are many factors that influence what medications should be included in an algorithm. As it pertains to storage, temperature, naming, packaging, varying concentrations, and compatibility requirements should be thoroughly planned out prior to medication selection and storage.

#### **6.4 Temperature**

When choosing medications to be included in local EMS protocols, the ability to store a medication at an appropriate temperature is important for both patient safety and cost reduction. For instance, an advanced life support (ALS) crew would typically align protocol medications with what is preferred at the receiving facilities. In the case

*Patient Safety in Emergency Medical Services DOI: http://dx.doi.org/10.5772/intechopen.108690*

of benzodiazepines, lorazepam is often preferred for sedation within emergency departments because of the longer half-life and smaller individual dosages. However, this may be impractical for EMS use, as it experiences statistically significant degradation in warmer temperatures and must be replaced every 60 days [26]. For agencies operating in warmer climates, the degradation occurs even faster. Therefore, ambulances in hotter climates must be either stocked with midazolam, which does not degrade in higher temperatures, or have the ability to refrigerate lorazepam appropriately. Unfortunately, temperature degradation can occur with medications across all classes, necessitating cautious choices and strict medication rotation regimens to ensure efficacy. Using a medication with decreased potency or efficacy is certainly not in the best interest of a patient.

#### **6.5 Naming**

Medication names can be equally important to patient safety in the selection and storage process. Look-alike and sound-alike medication names are a common source of medication errors, whether due to EMS clinician confusion or grabbing the wrong medication because they were stored in proximity. For example, a paramedic might intend for a patient with stable rapid atrial fibrillation to receive diltiazem, but what if it were stored next to diazepam and was administered instead? Not only would the patient not receive the appropriate medication but it would also become difficult to assess stability of the patient, as they would likely become lethargic and possibly hypotensive due to the adverse effects of the benzodiazepine. In cases where lookalike and sound-alike medications are both part of the EMS protocols, these should be clearly labeled and stored in separate locations [27, 28].

#### **6.6 Packaging**

As with look-alike and sound-alike medication names, medications can also be packaged in similar vial sizes or box colors. Ideally, these issues would be engineered out of the system by manufacturers, and in some cases they are. However, there are numerous times when different medications from different manufacturers look similar. When storing medications with similar packaging, try to keep maximum distance between look-alike packages within the medication box. Additionally, agencies should point out these high-risk situations before they become a problem (i.e. when the new packaging is noted, staff should be notified of the similarities before using it with a patient). In the event of a mix-up, medication cross-checks could prevent a medication error due to packaging issues [27, 28].

#### **6.7 Medications with varying concentrations**

If possible, avoid procuring varying concentrations of the same medications unless medically necessary. For example, if ketamine was initially purchased at a concentration of 10mg/mL but became unavailable due to supply chain issues, necessitating a switch to a more concentrated 50mg/mL concentration, this could pose a significant threat to patient safety if both concentrations ended up in the same drug box. In order to avoid overdose, it would be appropriate to not only make clinicians aware of the change but also to remove all vials of the more dilute medication from all agency medication boxes. In cases where varying concentrations are necessary, such as in the case of epinephrine, clear labeling, separate storage sites, and medication cross-checks should be employed to prevent medication errors [28].
