An ambulance was dispatched to attend a 55 year-old patient with heart failure in the community. While treating this patient, a paramedic mistakenly pushes 4 milligrams of intravenous norepinephrine instead of the intended lookalike vial of 1 milligram of bumetanide (Bumex®).
The patient immediately develops a supraventricular tachycardia, becomes hypertensive, and deteriorates into ventricular fibrillation. Resuscitative efforts are unsuccessful; the patient is pronounced dead on arrival at the ED.
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- Identify and outline, from a quality systems perspective, the errors made by the paramedic in this clinical scenario
- Analysethe contributing human and system error factors and apply your findings to this case.
- Describe the process and systems actions you would recommend to improve patient safety and prevent a similar error by another paramedic
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