About the alerting of a rescue team without a hazard warning from the dispatcher´s perspective, as well as difficulties due to automated ECG analysis, you can read here:
1. An Emergency Call Due to Thallium Poisoning, Web Search, and Communication
First, we will examine this informative case from "cirs bayern" (cirs Bavaria) and pay particular attention to how it was investigated using the London Protocol. This case was described from the perspective of the rescue coordinating centre. Hence, most of the recommendations pertain to the work of such a centre.
1.1. The Caller Reported a Case of Thallium Poisoning
The caller told the dispatcher about a patient, who had ingested thallium(I) acetate "tablets" and was vomiting when the emergency call took place. The caller said that the dose had been "25 milligrammes".
Later, it turned out that the patient had taken 25 grammes of thallium(I) acetate. The circumstances of this ingestion are not mentioned in the CIRS report. Therefore, it is not clear, what the preparation of the chemical was like and what the reason for the taking had been.
1.2. The Web Search About Thallous Acetate
The dispatcher executed a short web search using the term "thallous acetate" and received "globuli" in conjunction with "medication" in his search results, amongst others. Due to that and presumably also because of the mentioned dose of 25 milligrammes, he did not assume that the ambulance crew could be in danger. Thus, he did not deliver a hazard warning.
1.3. The Rescue Team Contacted the Poison Information Centre
The rescue team learned about the true dose of 25 grammes at the scene and consulted the poison information centre. As the latter was overstrained with calls at that time, the team called a second poison information centre. There is no prioritised direct line available to emergency services.
Finally, the rescue team learned that the lethal dose of thallium is one gramme for humans and that nausea and vomiting are symptoms which occur during the first hours after ingestion.
2. The Poisonous Thallium(I) Acetate and Thallium Globuli
2.1. Thallium(I) Acetate
Thallium(I) acetate is a thallium salt which is used as a selective growth medium in microbiology, for instance. As it is very poisonous, it has earlier been employed as a rodenticide. Occupational exposure occurs in the cement-, paper-, glas-, and steelindustries, as well as in the production of fluorescent paint and pyrotechnics.
2.2. Thallium Globuli
Thallium globuli are available as various homoeopathic preparations in several potentiations. Due to the intense dilution series, there is no thallium in them any more, only its information shall be carried by the globuli. These can be taken against hair loss.
3. Investigation of the Communication About Thallium(I) Acetate Using the London Protocol
"cirs bayern" has processed the case in a structured manner, using the London Protocol, as follows.
3.1. The Core Problem of the Thallium Case
Insteaad of thallium(I) acetate, the dispatcher had searched for "thallous acetate", which lead to results that did not provide a clue to an imminent danger. According to "cirs bayern", the search results, which Google shows, have been adapted, most likely because of an increased number of searches for "thallium poisoning". After his search, the dispatcher did not see any necessity to warn the ambulance crew against a hazard.
3.2. The Faulty Procedure
Due to the false indication of quantity, which the caller had provided, and the search result, the ambulance crew was not warned against the danger caused by a hazardous material.
3.3. Contributory Factors According to the Categories of the London Protocol
Organisational and Management Factors:
Without a prioritised direct line to the poison information centre for emergency services and the rescue coordination centre, making contact rapidly was not possible.
Author´s note: This call was made by the rescue team in the first place. Possibly, the dispatcher would have called if he had had a direct line to the poison information centre.
Task and Technology Factors:
Dispatchers can only obtain limited help from specialists, such as the Analytical Task Force, ATF, on the phone in case of an emergency which involves a hazardous material. Reference books such as the German Red List and the Yellow List (Rote und Gelbe Liste), which are reference works for medications, or the "GESTIS-Stoffdatenbank", a database with information on hazardous materials, are not directly accessible via the system which is used to dispatch the rescue teams.
In addition, the responsibility to teach their staff how to execute such searches lies with the respective rescue coordination centres. There is no uniform regulation which applies throughout Bavaria.
Work Environment Factors:
A rescue coordination centre´s employees have access to the hazardous substance database Memplex (TM), which does not contain medications, though. As the dispatcher primarily thought of a drug, he performed a general web search.
Individual Factors:
The caller had mentioned the wrong quantity of "25 milligrammes" instead of "25 grammes". It is not known whether the dispatcher had checked the plausibility of this indication.
3.4. The Recommended Intervention Measures
The following measures have been suggested by the employees of "cirs bayern":
- the creation of a database for professional seach, which contains drugs along with hazardous materials
- a rework of the recommendations concerning the structured processing of an emergency call with respect to hazardous substances to be executed by the Bavarian Rescue Service Committee
- the implementation of direct lines to professional services such as the poison information centre, available to rescue coordination centres and ambulance services
- Bavaria-wide training of dispatchers regarding the search of unknown substances
- Bavaria-wide training of emergency service personnel concerning the personal protective equipment to be worn during calls involving hazardous materials
"cirs bayern" does not document the implementation of the recommended measures. Therefore, we are unable to find out to what extend the respective organisations have made improvements.
4. What We Learn From the Thallium Case
After having studied the investigation of the case using the London Protocol, including the recommendations for the work of rescue coordination centres, in subchapter 3, we will now address the points which we can apply at our own workplaces.
From a CRM point of view, the faulty procedure can be seen as a fixation error. Below, we will define this type of error and apply it to the thallium case before we explore what we can do about it.
4.1. Fixation Errors Are Difficult to Recognise
Definition of the Fixation Error
We make such mistakes when we fixate on a diagnosis or a decision prematurely. This happens when we cling to a piece of information, or a selection of symptoms and don´t take all other possibilities into account, which could be deducted from our information, as well. A concrete example is a working diagnosis, which is being adopted uncritically and established as the final diagnosis without any further differential diagnostic thinking.
The Potential Fixation in the Thallium Case
Presumably, the dispatcher thought of a drug primarily because of the combination of the quantity of "25 milligrammes" and his search result "globuli" and, therefore, did not warn the crew against the danger due to the poisonous thallium(I) acetate.
This is a contemplation in hindsight of the case. It is important, though, to take the limited amount of time and the restricted access to professional reference works into account.
Fixation Errors Are Treacherous and Difficult to Recognise
Especially in complex situations in which pieces of information of various sorts have to be processed simultaneously, whilst teamwork has to be coordinated, and decisions have to be made, fixation errors happen fairly often.
They occur if we don´t question information or if we have already made up our mind and, following that, don´t allow further directions in our thinking. This does often happen unknowingly. Rather, the many facettes of a complex situation exert their influence on this.
General Tips on how to Deal With Fixation Errors:
- familiarising oneself with the issue "fixation error" as such
- investigating the fixation errors made together as a team
- reading cases about it in CIRS databases
- developing a feel for the patterns of fixation errors
- it is important to know that we cannot avoid them completely
CRM Techniques to Avoid Fixation Errors
- cross and double check (never assume anything) (taken from the 15 CRM Key Points by Rall and Gaba); this pertains to any type of information
- use all available information (15 CRM Key Points), f. ex., don´t rely solely on one single statement of a relative, or a witness
- pay close attention during handovers, adopted diagnoses and specifications are dreaded sources of this type of error
- don´t be satisfied with the first diagnosis, or solution, think again critically
- ask all team members during a team time out, whether there has been overlooked anything
4.2. We Should Check the Plausibility of Indications of Quantity as far as Possible
The dispatcher must have deemed the indication of quantity trustworthy according to the report. This might have contributed to the fixation error.
How to Minimise Mistakes When Working With Indications of Quantity:
- always repeat indications of quantities orally and check their plausibility as far as this is possible
- reckon with discomposure and confusions, clarify precisely
- ask for concrete specifications on packages; regarding drugs, ask about the number of tablets taken
- caveat: be careful with packages of hazardous substances, there are contact poisons, self-protection must always be your first step
5. The NHS Summarises CIRS Cases in Reports
After having elaborated potential learning points from the thallium(I) acetate case for us, we will now turn our attention to the English National Health Service, NHS. Its employees present the registered CIRS cases in their reports.
These reports provide a summary of important cases and they also contain the implemented measures to avoid the described situations in the future. In all cases the organisations, which were contacted to discuss the identified safety risks and to make improvements, are mentioned.
We will use two cases about automated ECG analysis from the report of April to September 2019 as examples (page 28 and following). This report is available on the web page linked above. Unfortunately, this page was last updated on 11 February 2021 (most recently accessed 29 October 2023).
6. Two CIRS Cases With Respect to Automated ECG Analyses
6.1. An ECG Which Was Deemed "Normal" Initially
An ECG which was initially seen as "normal" turned out to be abnormal after the respective patient had died. This prompted the NHS employees to question the term "normal" and to discuss it with experts in the field of ECG analysis. They suggested to change the term to "no abnormalities detected".
The experts replied that the term "normal" complied with international standards and, therefore, an attempt to change it would have no prospect. However, they said that they worked continuously to emphasise in medical training, how important it is that human beings analyse an ECG.
Unfortunately, it is not known whether the manual analysis of the ECG would have lead to a decisive diagnosis and, thus, might have altered the course of the disease.
6.2. When Age and Sex Are Not Manually Selected Prior to ECG Recording
If medical personnel does not preselect a patient´s age and sex on the ECG device prior to ECG recording, the device sets the parameters to "male" and "50 years" by default. In the automated analysis, the consequence might be that abnormal findings are classified as normal.
This is relevant to the diagnosis of a myocardial infarction, for instance, as the deviation from the normal lines are defined in millimetres. The values, which indicate a myocardial infarction, vary according to the respective sex and age.
On the one hand, one should postulate that age and sex be indicated as "unknown" in case of a missing input. On the other hand, also this incident shows how important a human ECG analysis is.
7. Especially in the Light of Automation the True Art of Healing Becomes Visible
Even though automated processes deliver results rapidly and, hence, make work faster overall, we as human beings are still an important supervisory authority. This holds true in medicine, as well. Especially when analysing an ECG, the findings must be seen in conjunction with the patient´s clinical presentation, as well as further examination reports.
Therefore, we should never rely on devices alone. Rather, we should never lose our sight of our patients and apply critical thinking and experience in order to perform the true art of healing, which considers the big picture.
8. Important Interrelations for Teamwork in the Next Article
In the next article, we will discuss the interrelations between the authority gradient, three types of behaviour, from submissiveness to aggressiveness, and teamwork. This is an exciting topic with consequences for safety.
Author: Eva-Maria Schottdorf
Date: October 30th, 2023
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