A third dose of adrenaline was incorrectly administered, causing the patient to go into cardiac arrest. Photo / 123RF
A third dose of adrenaline was incorrectly administered, causing the patient to go into cardiac arrest. Photo / 123RF
A woman thought she was going to die after a medical professional incorrectly administered a third dose of adrenaline, causing her to suffer a cardiac arrest.
The incident occurred in January last year when the woman went into anaphylactic shock and required emergency medical assistance.
According to areport released today by deputy health and disability commissioner Rose Wall, an ambulance arrived at her home with a paramedic and an Emergency Medical Technician (EMT).
The paramedic gave the woman 5mg of adrenaline through a nebuliser, then 0.5mg was administered intramuscularly (IM) by the woman’s neighbour, who was an off-duty nurse, under the supervision of the paramedic.
A third dose was drawn into a syringe by the paramedic and handed to the EMT, without instruction on the intended administration method.
As the dose was intended for the nebuliser it was 4mg, which was significantly higher than the recommended dose to be given via IM or intravenously.
The third dose was then administered intravenously by the EMT in error without the awareness of the paramedic, who was on the phone to the ambulance service’s air desk at the time.
Within one minute, the woman suffered a cardiac arrest and required resuscitation and defibrillation. Her heart rhythm returned shortly after.
She went on to tell the HDC that after the third dose of adrenaline was given she heard someone say something along the lines of ‘”too much adrenaline”.
The woman recalled feeling “incredible pain in her brain and chest” and telling her husband: “I think I am going to die.”
Following an investigation into whether the ambulance service provided the woman with the appropriate standard of care, Wall found the paramedic and EMT had breached the Code of Health and Disability Services Consumers’ Rights.
According to her report, the EMT was not qualified to administer medication intravenously and had acted outside of her scope of practice.
It then took three hours for medical staff to understand why the patient had gone into cardiac arrest because no one, except the EMT who had administered it, knew it had been given intravenously.
The paramedic told the HDC she remembered handing the syringe to the EMT and telling her it was for the nebuliser, while the EMT said she was only told to administer it.
The paramedic also said that she assumed the EMT would know to use the nebuliser because she wasn’t qualified to administer it intravenously.
However, the EMT said she felt she was unable to seek clarification from her superior, who was busy with other tasks at the time.
“[The paramedic handed me an unlabelled syringe and] did not state the drug, the route, the dose or any other information at that moment as required by [ambulance service] procedures,” she told the HDC.
“I have identified that at that moment I was frozen … I felt powerless, I did what I was told and I could not interrupt the authority figure on the phone.”
The paramedic told the HDC that after the woman was transferred to hospital she began researching adrenaline overdoses as she could not understand why she had gone into cardiac arrest.
It was not until later that the cause was identified.
Deputy health and disability commissioner Rose Wall investigated the patient's care.
The EMT said she was deeply ashamed by what had happened and she wished she had had the strength to seek clarity on the paramedic’s instruction.
“I am sorry that I did not pause before acting.”
Wall was critical of the way the EMT handled the incident.
“No information has been provided to indicate that when faced with uncertainty, the EMT sought clarification or advice,” she said in her report.
“I am especially critical of the EMT in this regard and consider this an egregious breach of the standards.”
But Wall said that regardless of the EMT’s actions, the paramedic was responsible for all aspects of medicine administration.
She concluded the paramedic did not provide clear instructions to the EMT nor did she adequately supervise the EMT.
“Having reviewed the available information, it is clear that [the EMT] was not supervised after being delegated the task of administering adrenaline,” she said.
Wall recommended the paramedic and the EMT engage in further training on anaphylaxis and adrenaline and work on their communication and teamwork.
She also recommended they write a letter of apology to their patient within three weeks of the ruling.
Jeremy Wilkinson is an Open Justice reporter based in Manawatū covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.
