ACPIC 2020: Cases around the world: Sentinel Event – IV Adrenaline instead of Morphine


In October 2020, ACP was pleased to deliver our first fully online and interactive paramedic conference. The conference attracted over 1100 attendees, 60 speakers and 36 sessions.

Presented by: Andrew Keenan, Paul Misasi & Howard Wren

In this presentation, the panel will discuss a fictional case study – about a common drug error when administering IV Adrenaline instead of morphine.


Howard Wren - Chief Officer, ACT Ambulance

Andrew Keenan - Having worked for more than 30 years in the primary care environment, Andrew has a passion for patient safety and experience. Andrew commenced his journey in the pre hospital environment as a Medical Assistant with the New Zealand Defence Force (NZDF). Following this, Andrew completed vocational training as an volunteer ambulance officer, leading to a fulltime role as a paramedic with St John New Zealand. 

Taking a break from the ambulance sector, Andrew joined Auckland District Health Board as the first ever non-registered nurse in the role as a “Duty Manager” across Auckland City, National Women’s and Starship hospitals. Andrew was promoted into senior leadership roles with ultimate responsibility for leading the quality and patient safety team for 9 years.  Specialising in reviewing patient outcomes through in-depth case reviews and root cause analyses, Andrew was pivotal in the training of over 400 staff in root cause analysis (RCA) methodology.  

With a passion for the pre hospital environment Andrew returned to  Auckland University of Technology (AUT) to complete a Bachelor of Health Science (Paramedicine)  and postgraduate studies in emergency management. Wanting to return to frontline ambulance services, Andrew, joined Wellington Free Ambulance, leading the emergency management team for two years and was fundamental in the development of a coordinated approach to working with specialist teams such as NZDF and New Zealand police force. Four years ago Andrew took up his current role – Director, Patient Safety and Experience at Ambulance Victoria. He has met the challenge of developing a clinical governance framework with a specific focus on embedding an organisational wide patient safety culture. 

Paul Misasi - Paul has been a paramedic for 17+ years and currently serves as the Deputy Director of Operations for Sedwick County Emergency Medical Service, the largest and busiest EMS agency in the state of Kansas, USA. Paul is a doctoral candidate in Human Factors Psychology at Wichita State University and specializes in cognitive engineering. He holds a Masters degree in Emergency Health Services from the University of Maryland, Baltimore County, and a Masters degree in Psychology and Bachelors of Science in Health Service Organization & Policy from Wichita State University. He is the first paramedic/ ambulance service manager to achieve certification as a Certified Professional in-Patient Safety through the National Patient Safety Foundation.

Presented by Andrew Keenan, Paul Misasi & Howard Wren



45 minutes
9th Feb 2021
Member free
Non-member $19
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