Medication prescribing errors in the prehospital setting and in the ED.

BACKGROUND: Medication errors are a common cause of iatrogenic adverse drug events. The incidence and nature of medication errors during prehospital treatment have not been fully described. OBJECTIVES: The objectives of this study are to describe the incidence and characteristics of medication errors in adults during prehospital emergency treatment and in the emergency department (ED) and to identify risk factors for medication errors in those settings. METHODS: This is a retrospective study of adult patients transferred by emergency medical services to the ED of a university-affiliated hospital in Israel. The drugs administered in the mobile intensive care unit and in the ED were reviewed by 2 reviewers, who independently decided whether an error had occurred. The primary outcome was the number of drug errors per patient. Secondary outcomes were the type and severity of the errors and variables associated with increased incidence of drug errors. RESULTS: During the study period, 1837 patients were brought to the ED by mobile intensive care unit vehicles. Five hundred thirty-six patient charts (29%) were randomly selected for review; 65 charts (12.12%) could not be found; thus, 471 charts were reviewed. In the emergency vehicle, 188 patients (45.63%) received medications; of those, 12.76% (24 patients) were subject to a medication error. The number of drugs administered and long evacuation times were associated with higher risk for an error (P<.01 and P=.011, respectively). The presence of a physician in the emergency vehicle did not alter the risk of an error (P=.95). In the ED, 332 patients (72.6%) received medications. Of those, medication errors occurred in 120 patients (36.1%). The more medications administered, the higher the risk of error (P<.01). Less errors occurred in trauma patients (P=.041). CONCLUSION: More medication errors occur in the ED than in the emergency vehicles. Patients treated with multiple medications are more prone to medication errors.

[The pre-hospital medical treatment of the victims of multi-casualty incidents caused by explosions of suicide bombers during the Al-Aksa Intifada--April 2001 to December 2004: the activity and experience gained by the teams of Magen David Adom in Israel].

This article deals with the pre-hospital medical treatment provided by Magen David Adom (MDA) teams to the victims of 36 multi-casualty incidents caused by suicide bombers during the Al-Aksa Intifada. A total of 2048 people were injured in those 36 incidents--an average of 57 injured per incident. The data collection and analysis is based on operational and medical debriefing performed after each incident, with the participation of all MDA teams that treated and evacuated injured that were defined as urgent. The medical debriefing focused on: triage--the definition of the injured situation: urgent or not urgent, priority for treatment and priority for evacuation; the Level of treatment--advanced life support (ALS) (paramedics and physicians) in comparison with basic life support (BLS) [medics]; life saving procedures performed on the scene; and the way in which the teams on the scene decided on the hospital in the region to evacuate the injured. DATA COLLECTED: MDA forces amassed [average per incident)--42 ambulances and 116 health providers. The timetable from the time of the explosion (average per incident] included: arrival of first ambulance--3.9 minutes and the evacuation of the first urgently injured from scene--10.7 minutes. The evacuation of the last urgently injured from the scene was 25.2 minutes. DATA ANALYZED: Triage data showed that: 70% of the injured defined on the scene as urgent had a moderate--ISS > 9, or severe ISS> 16 injury. Life-saving procedures were performed on the scene on 99 victims [24% of all injured defined as urgent by MDA teams). Findings on decision-making regarding which hospital to evacuate the urgently injured revealed: 9 incidents took place in regions where Level 1 trauma centers were not available--all urgently injured were evacuated to regional hospitals, 63% of these patients were secondarily transferred to a Level 1 trauma center. In 27 incidents--one or more Level 1 trauma centers were available in the region and 71% of the urgently injured were transported directly from the scene to Level 1 trauma centers. Only 12% of those transported to regional hospitals were secondarily transported to Level 1 trauma centers. Even in multi-casualty incidents caused by explosions of suicide bombers, incidents that are characterized by stress, confusion and chaos--MDA teams succeeded in organizing the medical activity on the scene, acted professionally and provided medical treatment to those who were severely injured. This pre-hospital performance of MDA teams had a significant contribution to the successful treatment of the victims of those events by the entire trauma system in Israel.

Terrorist suicide bombings: lessons learned in Metropolitan Haifa from September 2000 to January 2006.

BACKGROUND: The threat of suicide bombing attacks has become a worldwide problem. This special type of multiple casualty incidents (MCI) seriously challenges the most experienced medical facilities. METHODS: The authors concluded a retrospective analysis of the medical management of victims from the six suicide bombing attacks that occurred in Metropolitan Haifa from 2000 to 2006. RESULTS: The six terrorist suicide bombing attacks resulted in 411 victims with 69 dead (16.8 percent) and 342 injured. Of the 342 injured, there were 31 (9.1 percent) severely injured, seven (2.4 percent) moderately severely injured, and 304 (88.9 percent) mildly injured patients. Twenty four (77 percent) of the 31 severely injured victims were evacuated to the level I trauma center at Rambam Medical Center (RMC). Of the seven severely injured victims who were evacuated to the level II trauma centers (Bnai-Zion Medical Center and Carmel Medical Center) because of proximity to the detonation site, three were secondarily transferred to RMC after initial resuscitation. Eight of the 24 severely injured casualties, admitted to RMC, eventually died of their wounds. There was no in-hospital mortality in the level II trauma centers. CONCLUSIONS: A predetermined metropolitan triage system which directs trauma victims of a MCI to the appropriate medical center and prevents overcrowding of the level I facility with less severe injured patients will assure that critically injured patients of a suicide bombing attack will receive a level of care that is comparable with the care given to similar patients under normal circumstances. Severe blast injury victims without penetrating injuries but with significant pulmonary damage can be effectively managed in ICUs of level II trauma centers.

[Do the emergency medical services need more paramedics? An examination of supply and demand].

BACKGROUND: Paramedics are a critical national resource. The paramedic workforce is dynamic and has never been studied, thereby limiting the possibility of appropriate planning. OBJECTIVES: To examine the present and projected supply and demand for paramedics, the balance between supply and demand, and how this affects the planning of the paramedic workforce. METHODS: Supply was assessed by the annual number of graduates of paramedic training programs, the duration of stay in the profession and the likelihood of staying in the profession, using data obtained by structured telephone interviews with a sample of graduates of paramedic courses. Demand was assessed by interviewing key figures in the emergency medical services (EMS). RESULTS: There are about 1000 certified paramedics in Israel. Of them, 64% are active in the civilian labor market. If the demand does not change beyond the natural annual increase of two advanced life support (ALS) ambulances (which are staffed by paramedics), there may be a surplus of 180 paramedics by 2010. Increased demand outside the EMS may temporarily absorb this surplus, but it will reappear by 2015 or 2020. Conversely, upgrading all ambulances to ALS vehicles will result in a shortage of 400-900 paramedics by 2010 (depending on the number of paramedics per vehicle) if the number of paramedics trained annually is not increased. CONCLUSIONS: These findings may provide a better basis for long-term planning for training, recruitment, and employment of paramedics and may serve as an example for workforce planning for other health professions.

Stress, work overload, burnout, and satisfaction among paramedics in Israel.

INTRODUCTION: The number of paramedics in Israel is increasing. Despite this growth and important role, the emergency medical organizations lack information about the characteristics of their work. OBJECTIVE: The objective of this study was to examine the characteristics of the paramedics' work, the quality of their working lives, the factors that keep them in the profession, or conversely, draw them away from it. METHODS: Cross-sectional study conducted through telephone interviews of a random sample of 50% of the graduates of paramedic courses in Israel (excluding conscripted soldiers). RESULTS: The factors that attract paramedics to the profession have much to do with the essence of the job-rescuing and saving-and a love of what it involves, as well as interest and variety. Pressures at work result from having to cope with a lack of administrative support, paperwork, long hours, imbalance between work and family life, and salary. They do not come from having to cope with responsibility, the pressure of working under uncertain conditions, and the sudden transition from calm situations to emergencies. Dissatisfaction at work is caused by burnout, work overload, and poor health. Physical and mental health that impedes their ability to work is related to a sense of burnout and the intention to change professions. CONCLUSIONS: The findings about the relationships between health, job satisfaction, and burnout, coupled with the fact that within a decade, half of the currently employed paramedics will reach an age at which it is hard for them to perform their job, lead to the conclusion that there is a need to reconsider the optimum length of service in the profession. There also is a need to form organizational arrangements to change the work procedures of aging paramedics.

A multicasualty event: out-of-hospital and in-hospital organizational aspects.

UNLABELLED: In a wedding celebration of 700 participants, the third floor of the hall in which the celebration was taking place suddenly collapsed. While the walls remained intact, all three floors of the building collapsed, causing Israel's largest disaster. OBJECTIVES: To study the management of a multicasualty event (MCE), in the out-of-hospital and in-hospital phases, including rescue, emergency medical services (EMS) deployment and evacuation of casualties, emergency department (ED) deployment, recalling staff, medical care, imaging procedures, hospitalization, secondary referral, and interhospital transfer of patients. METHODS: Data on all the victims who arrived at the four EDs in Jerusalem were collected through medical files, telephone interviews, and hospital computerized information. RESULTS: The disaster resulted in 23 fatalities and 315 injured people; 43% were hospitalized. During the first hour, 42% were evacuated and after seven hours the scene was empty. Ninety-seven basic life support ambulances, 18 mobile intensive care units, 600 emergency medical technicians, 40 paramedics, and 15 physicians took part in the out-of-hospital stage. At the hospitals, about 1,300 staff members arrived immediately, either on demand or voluntarily, a number that seems too large for this disaster. Computed tomography (CT) demand was over its capability. CONCLUSIONS: During this MCE, the authors observed "rotating" bottleneck phenomena within out-of-hospital and in-hospital systems. For maximal efficiency, hospitals need to fully coordinate the influx and transfer of patients with out-of-hospital rescue services as well as with other hospitals. Each hospital has to immediately deploy its operational center, which will manage and monitor the hospital's resources and facilitate coordination with the relevant institutions.

Evaluation of isoproterenol in patients undergoing resuscitation for out-of-hospital asystolic cardiac arrest (the Israel Resuscitation with Isoproterenol Study Prospective Randomized Clinical Trial).

The Israel Resuscitation with Isoproterenol Study included 79 consecutive patients with witnessed out-of-hospital asystolic cardiac arrest who were resuscitated with epinephrine and atropine and randomized to receive additional isoproterenol or no isoproterenol. The rate of return of spontaneous circulation and survival to hospital admission did not differ in patients receiving standard therapy and those receiving additional isoproterenol.

Evacuation priorities in mass casualty terror-related events: implications for contingency planning.

OBJECTIVE: To assess evacuation priorities during terror-related mass casualty incidents (MCIs) and their implications for hospital organization/contingency planning. SUMMARY BACKGROUND DATA: Trauma guidelines recommend evacuation of critically injured patients to Level I trauma centers. The recent MCIs in Israel offered an opportunity to study the impositions placed on a prehospital emergency medical service (EMS) regarding evacuation priorities in these circumstances. METHODS: A retrospective analysis of medical evacuations from MCIs (29.9.2000-31.9.2002) performed by the Israeli National EMS rescue teams. RESULTS: Thirty-three MCIs yielded data on 1156 casualties. Only 57% (506) of the 1123 available and mobilized ambulances were needed to provide 612 evacuations. Rescue teams arrived on scene within <5 minutes and evacuated the last urgent casualty within 15-20 minutes. The majority of non-urgent and urgent patients were transported to medical centers close to the event. Less than half of the urgent casualties were evacuated to more distant trauma centers. Independent variables predicting evacuation to a trauma center were its being the hospital closest to the event (OR 249.2, P < 0.001), evacuation within <10 minutes of the event (OR 9.3, P = 0.003), and having an urgent patient on the ambulance (OR 5.6, P < 0.001). CONCLUSIONS: Hospitals nearby terror-induced MCIs play a major role in trauma patient care. Thus, all hospitals should be included in contingency plans for MCIs. Further research into the implications of evacuation of the most severely injured casualties to the nearest hospital while evacuating all other casualties to various hospitals in the area is needed. The challenges posed by terror-induced MCIs require consideration of a paradigm shift in trauma care.

A prospective national survey of management and clinical outcome of acute myocardial infarction in Israel, 2000.

BACKGROUND: Little information is available on the clinical practice and implementation of guidelines for treating acute myocardial infarction patients in Israel. OBJECTIVE: To assess patient characteristics, hospital course, management, and 30 day clinical outcome of all AMI patients hospitalized in Israel during a 2 month period in 2000. METHOD: We conducted a prospective 2 month survey of consecutive AMI patients admitted to 82 of 96 internal medicine departments and all 26 cardiac departments operating in Israel in 2000. Data were collected uniformly by means of a hospital and 30 day follow-up form. RESULTS: During the survey 1,683 consecutive patients with a discharge diagnosis of AMI were included. Their mean age was 66 years; 73% were male. The electrocardiographic pattern on admission revealed ST elevation, non-ST elevation and an undetermined ECG in 63%, 34% and 4% of patients respectively. Aspirin and heparin were given to 95% of patients. Beta-blockers and angiotensin-converting enzyme inhibitors were given to 76% and 65% of patients respectively. Among hospital survivors, 45% received lipid-lowering drugs. Thrombolytic therapy was administered in 28% of patients, coronary angiography was used in 45%, and 7% of patients underwent primary percutaneous coronary intervention. The 7 and 30 day mortality rates were 7% and 11% respectively. CONCLUSIONS: This nationwide survey shows that one-third of the AMI patients in Israel are elderly (> or = 75 years). The survey suggests that clinical guidelines for the management of patients with AMI are partially implemented in the community. Data from large surveys representing the "real world" practice are of utmost importance for the evaluation of clinical guidelines, research and educational purposes.