Medication errors can result in death due to the use of high-dose epinephrine with parenteral administration. Studies show that labeling drugs through ratio expressions is inadequate and error-prone. Medication errors are a particular area of interest for me, so this paper caught my eyeâ¦.hereâs my summary of it. Solomon SL, Wallace EM, Ford-Jones EL, Baker WM, Martone WJ, Kopin IJ, Critz AD, Allen JR. Epinephrine injection, Amphastar, 1 mg/mL, 30 mL vial, 1 count, NDC 76329-9061-00 - discontinued; Epinephrine injection, Pfizer, 0.1 mg/mL, 10 mL 20 gauge LifeShield syringe, 10 count, NDC 00409-4921-34 ; Epinephrine injection, Pfizer, 1 mg/mL, 1 mL ampule, 25 count, NDC 00409-7241-01 - discontinued; Reason for the Shortage. There were low rates of either an anaphylaxis protocol, EAI, or decision support aid use. The dose of epinephrine used for a heart attack is much higher than the dose used for anaphylaxis. The Adrenalin brand of EPINEPHrine packaged in 30 mL vials never had that indication because it is formulated with preservatives. Response to: âMedication errors with push dose pressors in the emergency department and intensive care units Keywords: Epinephrine Anaphylaxis Medication error As a medication, it is used to treat a number of conditions, including anaphylaxis, cardiac arrest, asthma, and superficial bleeding. The patient, who also was a physician, went to the ER with signs of anaphylaxis. Itâs a paper by Benkelfat et al and is published in the September 2013 issue of the Journal of Emergency Medicine.. Benkelfat R, Gouin S, Larose G, Bailey B. It may also be used for asthma when other treatments are not effective. Synthetic epinephrine is also used as a medication for the following: To stimulate the heart during a cardiac arrest; As a vasoconstrictor (medication ⦠Look Alike Sound Alike (LASA) medications involve medications that are visually similar in physical appearance or packaging and names of medications that have spelling similarities and/or similar phonetics.Confusing medication names and similar product packaging may lead to potentially harmful medication errors. Approximately one hour ⦠It was hard to remain calm but having experienced two prior allergic reactions I knew epinephrine would provide instant relief. One in three patients will face a mistake during a hospital stay. 8 Many adverse effects have been reported including cardiac ischemia, acute myocardial infarction, respiratory arrest, ventricular dysrhythmias, coronary artery spasms, and fatal intracranial bleeding. Medication errors can result in significant morbidity and mortality and more costly care. Epinephrine as Medication. If preference cards are used, the circulating nurse should update any changes by initialing and dating the revision. Medication errors injure approximately 1.3 million people annually in the United States [3] and can be caused by ambiguities in product names, labeling, and dosing. Inhaled epinephrine may be used to improve the symptoms of croup. Look-alike drug names that contribute to wrong drug errors are pervasive. The need to prioritize epinephrine above all other medications; The IM dosing of epinephrine; The need to understand the different concentrations of epinephrine available and how to avoid medication errors that occur as a result; Clinical Vignette. Amphastar has epinephrine available. Taxonomy of Patient Safety Medication Errors 1. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. 9. Report from EMS: âThis patient was recently prescribed Levofloxacin for a presumed pneumonia by his family MD. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. How It Happened. They often, particularly in the case of epinephrine, have catastrophic consequences both for the patient and the well-meaning provider. RESULTS: Thirty-seven in situ simulations were performed. 1984 Jan 19;310(3):166-70. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Reliance on memory 2. Medication errors were 17.0 times less likely when pre-filled syringes were used (95% CI 5.2â55.5), and infusions prepared by pharmacy and industry were significantly more likely to contain the expected concentration (P<0.001 for norepinephrine and P=0.001 for epinephrine). Series of Actions ⢠Series of actions must be performed correctly by several members of the health care team. 1. A shortage of EPINEPHrine prefilled syringes may cause serious medication errors, with 1 death reported from an overdose of EPINEPHrine. J Emerg Nurs 2013;39:151-3. ampoules and vials in storage areas. To determine the most common errors of epinephrine administration during severe allergic-like contrast reaction management using high-fidelity simulation surrogates. During a procedure, a surgeon requested lidocaine 1% with EPINEPHrine 1:100,000 for injection as a local anesthetic and was handed a syringe containing what he thought was the requested medication. Standardized processes ⦠Real medications and supplies were obtained from their actual locations. Errors with EPINEPHrine 1 mg ampuls or vials. Last fall, the National Comprehensive Cancer Network (NCCN) sent a letter to member hospitals, calling for deployment of EPINEPHrine autoinjectors as a way to avoid wrong dose and wrong route errors (intravenous [IV] instead of IM) when ampuls or vials are used for severe allergic reactions or anaphylaxis. errors showed that 180 (64.3%) reached the patient and 11 (3.9%) resulted in patient harm. Nursing Medication Errors: 5 Stories That Will Make Nurses Double-Check Their Dosages ... To alleviate the symptoms of a patientâs allergic reaction, a nurse administered a dose of epinephrine directly into her bloodstream instead of into her thigh. Epinephrine is now labeled for mass dose, like other medications, which is an important step toward patient safety When I told the nurse what was happening, she rushed me to the trauma room where doctors and nurses encircled me. Medications are sometimes listed on the preference card with options (e.g., if local, use medication âAâ; if general, use medication âBâ). Immediately afterward, the patient experienced a cardiac arrhythmia leading to cardiac arrest. Medication errors can occur in the absence of injury to the patient. Epi label change will cut medication errors. Thirty-seven in situ simulations were performed. Medication errors involving EPINEPHrine,* a high-alert drug, 1 are known to happen. Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. N Engl J Med. A factor associated with the epinephrine-related medication errors is its availability in different concentrations, namely 1:1,000 and 1:10,000. Reports on accidental intravenous epinephrine overdose in children are extremely rare, although medication errors in the management of pediatric anaphylaxis seem to be frequent. MEDICATIONS 1mg/mL Epinephrine Injection, USP Isoproterenol Hydrochloride Injection, USP Neostigmine Methylsulfate Injection, USP ESTABLISHED NAME RATIO AMOUNT PER UNIT OF VOLUME . In addition, 70 events (25%) involved high-alert medications, the majority of which were infusions. Errors made during the prescribing phase of providing epinephrine were often propagated, leading to incorrect medication preparation and even intravenous, instead of intramuscular, administration of epinephrine in a quarter of cases. Epinephrine, also known as adrenaline, is a medication and hormone. Medication errors in the management of anaphylaxis in a pediatric emergency department. Paparella S. Epinephrine: a potpourri of potential medication safety risks.
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