2018 improving drug calculation performance in paramedics practicing in an emergency services environment

IMPROVING DRUG CALCULATION PERFORMANCE 1
Improving Drug Calculation Performance in Paramedics Practicing in an Emergency Services
Environment.
Robert S. Cole
COE 501: Introduction to Research and Evaluation in Education
Fall 2018
Dr. Pamela Kulinna

Improving Drug Calculation Performance in Paramedics Practicing in an Emergency Services
Environment.
The increasing complexity of healthcare, particularly in the acutely ill and injured, has
increased the importance of the use of solid mathematical skills in daily practice. Perhaps the
most common example of the use of math in healthcare is the daily computation of drug and IV
fluid administration rates. Although the use of technology has reduced the errors of drug doses
and fluid administration in the in-hospital setting, the use of similar technology is challenging in
the out of hospital setting.
While in the hospital, multiple resources, drug calculators, expert consultation, and a
multidisciplinary approach can improve patient safety while reducing the chance of computation
errors. Technology and Electronic Health Records (EHRs) often replace manual mathematical
computation with automated processes complete with checks, balances, and validations too. For
the field provider in EMS, the use of these safeguards is inconsistent or just not available.
Complicating the issue, in “the field” there is often only a single advanced provider caring for
the patient. This provider is often solely responsible for managing multiple lower level providers,
as well as formulating a plan of care, and performing calculations for medication doses, tasks
that are often distributed among other providers in the in-hospital setting. Also, this provider
may be fatigued, physiologically and cognitively stressed, operating in a suboptimal environment
with a high cognitive load, in a time-sensitive manner. The traditional academic preparation for
performing drug calculations is inadequate for this unique situation.
It is no surprise when several studies have (Lammers, et al., 2014; Hohenhaus & Frush,
2005 ) demonstrated abysmal performance in simulated patient encounters. Other studies (Barker

et al., 2002) have shown that drug calculation errors account for a substantial portion of
preventable medical errors and contribute to morbidity and mortality.
This literature review will examine the scope of the problem and challenges with
mathematical proficiency in out of hospital care. It will also explore interventions targeted at
improving performance in the out of hospital environment, and how they may be applied in
initial and continuing education models. The author hopes that improvement in drug calculations
will result in fewer medical errors and improved patient care.
School and Classroom Context
As an EMS educator, I provide both initial and continuing education for multiple levels
of Emergency Medical Services (EMS) providers, with a wide variance of experience levels and
competencies. Currently, I provide continuing education (CE) for approximately 650 field
providers (including about 200 advanced providers, i.e., Paramedics and Advanced Emergency
Medical Technicians) in the Ada County-City Emergency Medical Services System (ACCESS)
located in southwest Idaho. I also teach an initial Healthcare Education Program (HEP) for
paramedic and Advanced Emergency Medical Technicians (a lower level of provider) in the
local university (Idaho State University) and community college (College of Western Idaho)
setting. According to the National Registry of Emergency Medical Technicians (NREMT), most
EMS students (regardless of level) are male (75%) and white (85%). By comparison, my local
system purports about 65% male but 90% white students.
For this literature review, I am excluding the lowest two levels of provider, the
Emergency Medical Technician (EMT) and the Emergency Medical Responder (EMR).
Although I also participate in education at these levels, neither of these tiers require significant
amounts of medication calculation in their care of patients.

Advanced Emergency Medical Technician (AEMT) are post-secondary, non-degree
courses of study and may accept students with either a minimum of a high school diploma or
Graduate Equivalency Degree. Very few programs require additional educational perquisites,
much less specific math competence before entry. Most AEMT programs last 1-2 semesters (3-6
months) in duration.
By comparison, paramedic programs in the United States must be accredited with the
Commission on Accreditation of Allied Health Education Programs (CAAHEP), though beyond
that there is also little standardization. Initial paramedic education programs may be post-
secondary, non-degree certificate programs, or may be part of a more substantial bachelorette
degree. Most of the initial paramedic education is in a cohort program, meaning that the group of
students proceed through the program together and are ideally successful together. Compared to
the AEMT described above, paramedic programs may be more rigorous but still suffer from a
lack of standardization regarding length, standards, format, and mathematical emphasis. Most
students enter into their programs with little previous undergraduate or healthcare experience,
although about 45% of paramedic students will obtain a college degree of some sort by
completion of their course of study. While indeed not universal, most reputable and university-
based programs require additional mathematics education either at the 100 level or specifically a
healthcare-focused mathematics class ("What are the requirements to be a paramedic?", 2018).
After ascertaining initial mathematical fluency, a paramedic program may incorporate
problems of drug evaluations and fluid administration into case-based scenarios, formative
assessments, and summative testing. It would be inaccurate to say that proficiency in these
calculations is emphasized significantly, however, as specific mathematical testing is rare.

The continuing education I provide (with my fellow educators) is a mix of nationally
recognized standardized courses and smaller educational activities. The nationally recognized
courses are typically provided over a 1-2 day (8-16 hours) standardized format mandated by
certain organizations, such as the American Heart Association (AHA) or the National
Association of Emergency Medical Technicians (NAEMT). These so-called “card courses” are
fast-paced and assume that the provider has a minimum level of knowledge before entry. They
do not require independently validated mathematical fluency, and expressly permit the use of
calculators, charts and other aids during the class. Put another way, these classes do not reinforce
the mathematical performance of drug calculations, and in some ways inadvertently discourage
it.
Other continuing education may be provided in lecture, video/distributed education,
psychomotor activities, or other educational programs. Similar to the “card courses” these
programs assume a foundational level of mathematical aptitude that may not be current or may
have never been present in the student. These educational offerings focus on updating preexisting
knowledge and introducing new information, and therefore drug calculations are seldom
emphasized. These courses also may or may not include formative and summative assessments,
which also may or may not include simulated patient/case specific drug calculations.
To sum up the context of mathematical fluency regarding EMS education (both initial
and continuing) is that even in my combined programs, it receives only moderate emphasis in
primary education, and even less in continuing education.
Purpose

The purpose of this literature review is to explore practical instructional strategies that
will improve drug dosage calculation performance in paramedics functioning in the Emergency
Medical Services environment. Ideally, this will provide strategies to ensure a minimum level of
practical mathematical competency that applies to the “street level,” as well as maintain it.
Rationale
The Institute of Medicine published the white paper To Err is Human (National Academy
of Sciences, 1999), calling to task the entire medical community to detect, monitor, prevent, and
otherwise address medical errors. The authors concluded that medical errors contributed upwards
to 98,000 deaths in the United States every year. In 2001, the National Coordinating Council for
Medication Errors Reporting and Prevention (NCC-MERP) reported that 7 percent of medication
errors (the most common form of medical errors) were related to mathematical miscalculation. A
similar review in Australia found a startling 17% of in-hospital errors were also related to
medication administration (Barker, et al., 2002).
When looking at healthcare as a whole, not all of these errors may result in death or harm
to the patient. In fact, 95% of these errors do not result in patient harm (Weant, Bailey & Baker,
2014). In the acutely ill or injured, particularly pediatric patients, however, the risk of adverse
outcomes skyrockets (Kozer et al., 2002) .
This illustrates there is a need for understanding the contributing factors to mathematical
performance in EMS, and devising strategies to improve and sustain proper drug dose
calculations in the field. Compared to other allied health professions and nursing, the research
into paramedic performance in math (and other fields) is relatively sparse. Therefore, lessons and
research obtained in similar settings, such as the critical care unit, the emergency department,
and nursing education programs must be extrapolated to the field of EMS. Since the

mathematical skills required in the hospital and out are essentially the same, strategies that can
be applied to in-hospital providers in high acuity settings should be applicable to paramedics as
well.
Review of Literature
While To Err is Human certainly produced headlines in the US and abroad when it was
published in 1999, many medical professionals were unsurprised. The problem of medical errors
and poor mathematical performance is hardly new. As nursing practice increased (not to imply
that medical errors are solely the domain of non-physicians) so did the knowledge about medical
errors. Dexter and Applegate (1980) explained the difficulty in healthcare professionals in
performing simple dosage calculation, and again by Bayne and Bindler in 1988. A persistent
problem, it was again described by Ashby in 1997, seemingly refractory to modern system
improvements design to reduce errors. It was theorized that the increasing complexity of
medicine (and it’s associated math) is merely outstripping the ability of safety measures (such as
calculators and unit dose dispensing systems) to keep pace (Dexter & Applegate, 1980; Long,
1982). This theory seems especially true in the fast and critical area of emergency and critical
care, where paramedics operate.
Over almost 20 years have passed since To Err is Human was published, and the
knowledge base on medical errors has grown substantially. Looking specifically at mathematical
errors in drug calculations and clinical settings, Wolf et al. (2006) found less than 3% of
baccalaureate nursing students were considered highly proficient in medical math. Another
study found 1 in 5 medication orders have a error, and 17% of those are dosing calculation errors
(Barker, et al, 2002). Warburton (2010) observed that “Evidence from the UK and abroad

suggests that problems with numeracy among healthcare staff occur across professions.” All in
all, medical errors, medication errors, and drug calculation deficits seem to pervade healthcare.
An Overview of Medication Calculation Ability as it Pertains to Emergency Medical
Services
As discussed previously, mathematical difficulties pervade throughout both Nursing and
Paramedicine and are a major contributor to medication errors and medical errors as a whole
(Eastwood and Boyle, 2006, 2009). While the concern has been more thoroughly examined in
Nursing , it can be assumed it is at least as prevalent in paramedicine as the other allied health
professions (Eastwood and Boyle, 2009).
Since EMS research is sporadic, are there other similar settings and professions that may
provide insight into drug calculation errors? Acute care environments are healthcare settings
inside the hospital where patients are suffering from acute, often life-threatening injuries and
illnesses requiring a high level of acumen, and therefore are a good surrogate for EMS practice.
Acute care settings include Intensive Care Units (ICUs), Emergency Departments (EDs) and
other similar departments. Acute care settings, with presumably high levels of training and
diligence, also suffer from problems with numeracy (Nasari, Et Al., 2009). Kozer et al., (2002)
noted that one emergency department had an approximately 10% error rate in medication doses
of pediatric patients, and also noted the more severe the patient’s condition or the younger the
patient, the greater likelihood of an error. 20-34% of medication errors were related directly to
mathematical proficiency, particularly in critical children (Neuspiel & Taylor, 2013).
Intravenous injections and infusions are representative of the types of drug calculations
paramedics perform. When looking at intravenous injections and infusions in the ICU, error rates
were between 4 and 9%. (Valentin et al., 2009). This issue persists despite the advent of

increased safety procedures and automation (Leufer & Cleary-Holdforth, 2013), highlighting the
role of human performance and factors. In addition to numeracy difficulties, nature of emergency
care, and distracting environment (similar to the paramedic’s work environment as well) all
have been listed as co-factors in proper drug calculations in the previous studies (Valentin et al.,
2009, Neuspiel & Taylor, 2013, Nasari, Babatabar & Mortazavi, 2009). These difficult realities
would imply that demonstrated academic mathematical ability is not enough, but the ability to
perform mathematical calculations under real-world conditions is also essential.
Australia’s Malcolm Boyle and Kathryn Eastwood have studied and compared both the
paramedic and nursing professions mathematical proficiency in their country with unsurprising
results. In a 2009 meta-analysis of the limited literature on Paramedics, they concluded: “from
these limited studies indicate a significant lack of mathematical proficiency amongst the
paramedics sampled.” Exploring further, Eastwood and Boyle (2011) comment that when
evaluating nursing students, the average proficiency on drug calculation exams was a startling
51%. Also in a separate 2018 study of paramedics, Boyle and Eastwood again found that only
20% of paramedic students were able to pass a 12 question numeracy exam utilizing similar drug
calculations as they would encounter in real patients (Boyle & Eastwood, 2018). In broad
strokes, these researchers have repeatedly concluded that both nurses and paramedics numeracy
ability of both highly variable, insufficient, and directly tied to patient safety. Furthermore, the
repeated and longitudinal findings of poor mathematical ability in both paramedics and nurses
would seem to imply that current educational strategies and remedies are not adequate.
Adapting traditional education models for numeracy to healthcare education.
Given that current healthcare education has not solved the problem of nurse and
paramedic non-proficiency in drug calculations, are there solutions from outside of healthcare?

Two areas have been suggested as areas of emphasis, reducing mathematical anxiety and
improving formal mathematical preparation.
Mathematics anxiety has been shown to reduce the performance of numerical tasks in
adults (Pletzer, et al., 2015). It is believed that mathematics anxiety interferes with working
memory, and adversely affects performance (Osei-Boadi,2016). Since working memory is
accessed for complex cognitive tasks (like drug calculations) it is no surprise this phenomenon
would also hold in healthcare providers.
Again, using nursing as a stand in for paramedics, Joyce Melius (2012) explored the
relation of mathematics preparation and mathematics anxiety in Nurses and their performance
when performing drug calculations. Infusion calculations were answered correctly by 67-70% of
nurses, which is marginally better than other reports, but still distressing. Interestingly enough,
this study also found the most challenging type of calculation for this sample was a weight based
infusion of Dopamine, an archetypical EMS medication infusion. As expected, academic
mathematical preparation and level of anxiety both were directly tied to performance on the
assessment exams, while degree obtained, years experience as a nurse, and gender did not.
Similarly, Leufer and Cleary-Holdforth in their 2013 literature review on medication
errors in nurses, also looked at strategies to improve drug calculation performance. They
identified that while drug calculation errors were themselves multifactorial, the provider's
knowledge (or lack thereof) was often a common factor. Both of these papers would suggest
addressing mathematics anxiety, and academic mathematics preparation may improve
performance downstream.
Although the relationship of math anxiety to math performance is only associative
reducing math anxiety in EMS providers would seem to be a useful and prudent strategy. While

attempts to reduce mathematical anxiety, ideally begin in childhood (Tooke & Lindstrom, 1998),
the reality is healthcare education programs must address it in their adult students. Many
educators outside of healthcare suggest that how math is presented is as important as how it is
taught. Simply put, if a student is told “math is hard”, it will be much harder for them throughout
life (Tooke & Lindstrom, 1998; Ashcraft, 2002; Ludden, 2017). This phenomenon would appear
present across genders, nationalities, and ethnicities (Foley et al., 2017) and may have
application in HCEPs.
To see if employing strategies to reduce mathematics anxiety would improve
mathematics performance, James Took and Leonard Lindstrom undertook a quasi-experimental
study in 1998 with student teachers in a 4-5 year Teachers program. One group received
mathematics preparation via traditional format and programming. The experimental sample
received their mathematical education with manipulatives to bridge from abstract concepts to
concrete, practical uses. In addition, the experimental group received an education program
focused on addressing perceptions around math and reducing mathematics anxiety. While there
were several subgroups to both arms of the study, unsurprisingly the experimental group both
outperformed the control on mathematical assessments and also scored better on Mathematics
Anxiety Rating Scale for Adults (MARS-A).
Academic preparation in math has also been implicated as a factor affecting nurse and
paramedic numeracy. Looking at mathematical performance, there is a consistent association
with prerequisite mathematical preparation and post service success as well. Traditional EMS
(and nursing) education often assumes some level of proficiency before attempting a course of
study. But is this assumption accurate? A survey of 1st year nursing students at the University
of Southern Queensland (Australia) found only 35% of new students had had formal

mathematical preparation in the 24 months (Galligan et al., 2018). A substantial portion of
students (over 30%) had more than 10 years since their last formal math class, and a significant
portion (also over 30%) only had high school math in preparation. This same study found that
20% of these these students, despite many having “advanced placement/dual credit math” in
high school, still felt unprepared for the basic algebraic drug calculations that nurses use
everyday.
There is some criticism of traditional healthcare education as a whole (regardless of
discipline) lacking in proper emphasis on pharmacology in general and drug calculation in
specific (Morrison-Griffiths et al., 2002; Manias et al., 2002). By contrast, HEPs that apply a
holistic approach to mathematical literacy and performance seem to do better in performance
benchmarks (Van de Mortel, et al., 2014) than those who do not. Wright (2012) suggested a
multi-pronged, three stage approach to education including one on one tutoring, independent
guided study (workbooks), online programs, and subject matter expert instructed math classes,
followed by simulation and proctored clinical practice.
The most notable success story is from Southern Cross University (NSW Australia). In
this 2013 study, Van de Mortel et al. describes a “whole curricula” scaffolding approach to
address the problem of numeracy in Baccalaureate Nursing (BN) students. The researchers and
educations implemented curriculum changes that screened for mathematical proficiency at the
outset of the program, and funneled students in need to additional mathematics classes early in
their program. Additionally, mathematical performance was continually assessed (quarterly) the
final two years of the four-year program, with any scores less than 100% in two attempts
requiring remediation or removal from the program. Additional tutoring was offered, and online
drug calculation training was also used to supplement and remediate low performers. Most

notably, mathematics classes were taught by math instructors, rather than Nursing cadre.
Implementation of this “whole curriculum” approach resulted in an impressive increase in nurses
who demonstrated repeated drug calculation mastery from 44.6% to 100% in 3 years.
Several conclusions can be safely drawn from this literature. First, a deliberate attempt at
a reduction in mathematics anxiety via pedagogical methods may improve mathematics
performance in healthcare providers. Second, HEPs should assume a substantial portion of their
students, regardless of educational background, are wholly unprepared to utilize math in the
healthcare setting. As such, HEPs should design their program holistically to remedy this gap.
Thirdly, even in specialized healthcare education, there is a clear role for regular, meaningful
mathematics education taught by math teachers.
Introducing frequent medication calculation assessment and testing in a non-punitive
environment.
The ubiquitous “observer effect” (AKA “The Hawthorne Effect”) is a phenomenon that
performance/behaviors changes in subjects when being observed. Extrapolated to this topic,
frequent assessment (observation) may improve performance on assessments themselves.
Frequent assessments may increase self-correction among providers. Challenges to this include
emphasizing performance and education and eliminating punitive consequences as barriers to
improvement.
As discussed previously, when examining initial healthcare education, single, short-lived,
and one-off initiatives to improve numeracy in healthcare providers are of limited benefit
(Guntalib, 2015; Warburton, 2010), and repeated programs over intermediate time spans seem to
improve short-term gains (Eastwood, et al., 2015), but may not sustain long term improvement.
Holistic and ongoing initiatives seem to be very useful (Van de Mortel et al. 2014) in initial

education. But what about clinicians in the workforce? Unlike wine, mathematical skills do not
age well. Previous discussion would imply that paramedics will require repetitive, ongoing, and
frequent skill maintenance instead of focused case by case education. Returning to the Van de
Mortel study (2014), repeated high stakes assessments resulted in substantial net improvements.
Can similarly structured assessments show improvement in the workforce?
Introducing increased medication calculation into the simulation
Bridging the gap between the classroom and actual performance is crucial. Van de Mortal
et al. (2014) commented on this when they recognized that while requiring 100% mastery in their
research may be intimidating, “100% mastery is reflective of the unforgiving and complex
environment of clinical practice”. Noted emergency medicine physician, Kelly Wong
(@mcsassymd, 2018) tweeted “ I don’t know why I ever took calculus. I wish I had just taken
math classes where you have to multiply two numbers while someone is dying and everyone else
in the room is screaming at you”. Both these comments illustrate the underlying truth: Math in
healthcare is done under stressful and challenging conditions wholly unlike the classroom.
High fidelity real-time simulation has emerged as a valid and useful tool to bridge the gap
between the classroom and clinical practice (Hunter, 2015). Described as “High-Fidelity
simulation practices utilize realistic scenarios as teaching tools through the lens of the mastery
learning and experiential learning theories” (Boyer, 2017), in EMS, this most often means
placing a student in situations with responsive mannequins, props, simulated patients, and
simulated partners while using similar equipment and facing situations similar to what is
encountered in real practice. Other variations of simulation could be an online simulation, also
described by Wright (2009,2012) as “Virtual Learning Environments” (VLE). A student could be
given interactive virtual scenarios, with simulated real-time feedback in the form of EKGs, vital

signs and other clinical parameters. A student would be required to respond with a correct
selection of interventions from choices, including performing drug calculations and selecting
correct dosages. The question is can simulation (regardless of type) be used to improve
numeracy of providers?
Several researchers have explored simulation specifically in an EMS context (Boyer
2017;) Lammers et al. (2014) demonstrated that high fidelity simulation could replicate and
produce medication errors similar to real clinical practice. In over 60 simulations, they were able
to identify multiple broad categories of errors, for correction, including drug dosage errors.
Wright (2009) recommended the practice of drug calculations in VLE during the second stage
and clinical situations (scenarios) third stages of a 3 phase approach to teaching numeracy in
healthcare as well.
Provider adoption of simulation as an educational tool is a concern. Pearson et al. (2014)
explored if an online simulation would be acceptable to healthcare practitioners in several
settings and found it was well received. Power et al. (2013) found that 94.4% of EMS providers
in their study felt that the use of high fidelity simulation was useful. Another study of 405
nursing students also found acceptance and preference of “authentic” contextualized practice to
improve drug calculation capability (Ramjan et al., 2014). This would imply that not only can
simulation (in various forms) be useful to assess for and correct numeracy errors and deficits but
that EMS providers would be receptive to such a practice. More importantly, simulation seems to
be useful in identifying errors and correcting them before they occur on real patients.
Implications for Practice

It is clear that improving numeracy and overall mathematical aptitude is a crucial priority for
healthcare, and it seems that EMS is no exception. What are the implications for the profession,
moving forward?
Implication #1: Healthcare Education programs should adopt a comprehensive, holistic
approach to ensuring numeracy in its students.
While one can bemoan the lack of preparation of the modern student in primary and
secondary education endlessly before entering into the healthcare professions, such discussions
are distractions and purely academic. Practically speaking, EMS HEPs adopt the
recommendations and follow the examples from both Wright (2009) and Van de Mortal et al.
(2014). EMS HEPs should require screening and/or recent mathematic education prior to entry
into a program of study, and without exception programs funnel those who are at risk into
mathematical remediation. Additionally, screening and assessment for numeracy ability
appropriate to the level of drug calculations should be ongoing and frequent throughout the
course of study.
As the course of study progresses, EMS HEPs should adopt a multifaceted education plan
for teaching mathematics that ties the classroom directly to clinical practice. This effort should
include tutoring, face to face instruction, online learning, and simulation in various forms. Not
specific to the classroom, EMS HEPs should incorporate drug calculations and drug safety into
all parts of their education especially simulation practice and remediation. These programs
should deliberately de-emphasis the use of “crutches” in order to encourage fundamental
mathematical literacy in the clinical environment. Finally, EMS HEPs should employ subject
matter experts in mathematics (i.e., Math Educators) to teach clinical math as a distinct and

defined part of the curricula during the course. This education should include manipulatives to
relate math to clinical practice, as well as useful strategies to reduce math anxiety.
Implication #2: Improved mathematics education during ongoing education of healthcare
providers.
Addressing the existing and future workforce of EMS providers, EMS agencies and
medical directors should require numeracy assessment during hiring and onboarding to identify
providers who may need additional education, while anticipating that most providers (even
experienced ones) will have deficits and require support. EMS agencies and medical directors
require numeracy assessment on an annual or biannual basis to identify numeracy skill
degradation and promote maths maintenance. After this, EMS agencies and medical directors
should identify plans and processes to help providers remediate and meet standards. EMS
agencies and medical directors should de-emphasize the use of “crutches” (rapid reference
charts, mobile apps, etc) and emphasize the use of mathematical skills during competency
checks, skills stations, standardized courses, online education and simulation, while ensuring that
every educational activity have a numeracy component. Crutches should still be permitted in the
actual care of patients as recommended by current “best practices” in the industry. EMS
agencies and medical directors should develop policies and processes for ensuring that all
advance providers complete education and demonstrate competency on a yearly (or more often if
needed) basis, and develop plans for remediation and separation for providers who are resistant
or unable to comply.
Implication #3: Improved mathematical emphasis during initial and recertification.

Sadly, state and national accreditation bodies put little emphasis on mathematical skills during
boards for licensure. Since testing standards often drive the priorities of EMS educators, national
and state boards should shift emphasis to include basic numeracy performance. Such an
emphasis could be in the form of specific assessment stations and tests; or integrating drug
calculation criteria into existing assessments. Furthermore, state and national accreditation
bodies should set performance standards in skill stations and assessments to be reflective of
actual clinical practice. Providers should have to perform actual drug calculations such as the
aforementioned “Dopamine” weight based infusion. State and national accreditation bodies
should require specific clinical numeracy education on subsequent recertification. Currently,
although requiring many hours of education in a variety of medical conditions and situations, no
state nor the National Registry of Emergency Medical Technicians require specific education in
numeracy as part of recertification
Summary
The question of numeracy and ability to perform medication calculations is an issue of
patient safety more so than workforce development, and should be treated as such, yet a
substantial proportion of providers, perhaps the majority, are woefully incapable of consistently
performing clinical math either in a classroom or under stress. The solution to is not found in
simple, one-off, short lived initiates, but in a sustained, holistic, ongoing approach that begins
with initial education, continuing through initial certification and hiring, and endures throughout
the professional career of a paramedic. It must be reinforced and required by program
administrators and chief officers that oversee paramedics, as well as the administrative bodies
and medical directors that certify and license paramedics to practice. No single piece of the
solution is insurmountable from a technological perspective. Online education, specialized math

instructors, simulation, continuing education are all things that already exist and are available
today. The problem is inertia. 20 years since To Err is Human is 19 years too long for action to
occur. EMS, perhaps the most flexible and innovative of the healthcare professions, certainly can
lead the way.

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