Resident Receives Inaugural Safety Award
As she began to treat a patient for anaphylaxis, Lisa Derrick, M.D., a third year emergency medicine resident at Summa Akron City Hospital, ordered the administration of intramuscular epinephrine (1:1000). When she saw that a staff member was preparing to give the concentrated epinephrine intravenously instead, she immediately called out “STOP.” Dr. Derrick related, “I saw an action I suspected would be bad, and I gave a clear command. Everyone stopped what they were doing. It was a very powerful word at a critical moment.”
By stopping the epinephrine from being given intravenously, a potentially fatal medication error was averted, and the patient recovered fully from his anaphylactic reaction. However, the experience was an eye-opening lesson in how easily a potent medication could be given incorrectly and how prone the system was to human error. Dr. Derrick began working on a safety initiative with Scott Wilber, M.D., MPH, Chair of the Department of Emergency Medicine, and the Emergency Department pharmacists and nursing supervisor. The goal of the safety initiative is to make epinephrine (1:1000) difficult to administer intravenously and to remove the current reliance on human memory for proper intramuscular administration. With the creation of the Epinephrine for Anaphylaxis kit, they expect to achieve this goal.
The Epinephrine for Anaphylaxis kit contains all the supplies necessary to administer epinephrine intramuscularly. There are also bold reminders on both the outside and inside of the kit for proper dosing and route of administration, including step-by-step instructions. The syringe in the kit is one that is not as familiar to staff and is more difficult to connect to the IV tubing, so it prompts questioning and reflection if staff attempt to give the medication IV. All individual ampules of epinephrine (1:1000) are being removed from the Pyxis machines so that no one can circumvent using the kit.
The kits are currently in use at Summa Akron City Hospital and are also in the process of being introduced to all Summa Emergency Departments, including Summa Barberton Hospital, Lake Medina, Green and the Summa Health Center at Wadsworth-Rittman. Dr. Derrick continues to improve the kits, currently working on designing a syringe that is 100 percent incompatible with IV tubing, which would render IV administration nearly impossible.
Dr. Derrick was recognized as the innaugural recipient of the Resident Patient Safety Award at the Summa Health Employee Recognition Celebration.
“Safety should always be foremost on our minds,” shared Dr. Derrick. “My participation in this safety initiative occurred because I was involved in the inciting event, but having the opportunity to contribute to this project has made me much more interested in safety improvement. Fortunately, the culture has changed, and transparency is encouraging us to admit our mistakes so that we can improve.”
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