Primary Care Paramedic-administered Ketamine in British Columbia, Canada: A Patient Safety-focused Observational Study.

Expanding the scope of Primary Care Paramedics (PCPs) in British Columbia to administer intranasal ketamine for pain was associated with several safety concerns. A review of the first 100 patient encounters found that 74% met the clinical practice guideline criteria (adult, trauma, moderate-to-severe pain). A dosage error rate of 11.2% (deviation greater than 5 mg) was identified, and in 14 cases paramedics administered ketamine without mandatory clinical support. Documentation errors occurred in 25% of encounters, especially for pain scores, weight, and vital signs, possibly indicating incomplete assessments. No adverse patient outcomes from dosing errors or missed consultations were observed. The findings highlight the need for improved guideline compliance and documentation before broader implementation.

Study at a glance

Abstract

In Western Canada, British Columbia Emergency Health Services (BCEHS) aimed to enhance prehospital pain management by authorizing Primary Care Paramedics (PCP) to administer intranasal (IN) ketamine. The objective of this study is to describe patient safety implications of expanding PCP scope to include IN ketamine. This retrospective, observational study reviewed patient care records of the first 100 consecutive patient encounters where PCPs administered IN ketamine for pain between December 2020 and September 2021. Data analysis used the Canadian Quality and Patient Safety Institute and Rights of Medication Administration frameworks. Of the 100 patients, 74% met the analgesia clinical practice guideline (CPG) criteria: adult, trauma, and moderate to severe pain. Most injuries (31%) involved extremities or hips/pelvis (18%). With 6 cases missing data, an 11.2% dosage error rate (>5 mg deviation) was identified. In 14 cases, PCPs did not contact mandatory clinical support and administered ketamine outside of the CPG. Documentation errors occurred in 25% of patient encounters, particularly with pain scores (20), patient weight (15), and vital signs (8), possibly indicating incomplete patient assessments. No instances of adverse patient outcomes resulting from dosing errors or missed consultations were observed throughout the study. This study highlights the safety implications of PCP-administered ketamine, including concerns about weight-based dosing, CPG compliance, and documentation standards. The key competencies of the Canadian Patient Safety Institute framework offer a foundation for addressing these safety concerns before expanding ketamine administration for broader PCP practice.