epinephrine medication errors

Medication errors with inhalant epinephrine mimicking an epidemic of neonatal sepsis. Thirty-seven in situ simulations were performed. Approximately one hour â¦ The dose of epinephrine used for a heart attack is much higher than the dose used for anaphylaxis. Solomon SL, Wallace EM, Ford-Jones EL, Baker WM, Martone WJ, Kopin IJ, Critz AD, Allen JR. Epinephrine is now labeled for mass dose, like other medications, which is an important step toward patient safety Medication errors in the management of anaphylaxis in a pediatric emergency department. As a medication, it is used to treat a number of conditions, including anaphylaxis, cardiac arrest, asthma, and superficial bleeding. Lack information access 3. How It Happened. Reliance on memory 2. Standardized processes â¦ The Adrenalin brand of EPINEPHrine packaged in 30 mL vials never had that indication because it is formulated with preservatives. 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. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. 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). 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. I urgently needed epinephrine, a potent medicine that could halt my life-threatening symptoms. Look-alike drug names that contribute to wrong drug errors are pervasive. Report from EMS: âThis patient was recently prescribed Levofloxacin for a presumed pneumonia by his family MD. It was hard to remain calm but having experienced two prior allergic reactions I knew epinephrine would provide instant relief. A shortage of EPINEPHrine prefilled syringes may cause serious medication errors, with 1 death reported from an overdose of EPINEPHrine. 9. They often, particularly in the case of epinephrine, have catastrophic consequences both for the patient and the well-meaning provider. Epinephrine, also known as adrenaline, is a medication and hormone. MEDICATIONS 1mg/mL Epinephrine Injection, USP Isoproterenol Hydrochloride Injection, USP Neostigmine Methylsulfate Injection, USP ESTABLISHED NAME RATIO AMOUNT PER UNIT OF VOLUME . N Engl J Med. Error-proof procedures 4. 1. The patient, who also was a physician, went to the ER with signs of anaphylaxis. Series of Actions â¢ Series of actions must be performed correctly by several members of the health care team. Real medications and supplies were obtained from their actual locations. There were low rates of either an anaphylaxis protocol, EAI, or decision support aid use. 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. RESULTS: Thirty-seven in situ simulations were performed. The surgeon injected the medication into the surgical site. 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. One in three patients will face a mistake during a hospital stay. 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. Epinephrine Medication Errors Related Research Unique Instruments Topic Difficulties Strengths & Weaknesses Ideas & Approaches AMERICAN PHARMACEUTICAL ASSOCIATION LISTED EPINEPHRINE ON THE HIGH RISK LIST FOR MEDICATION ERRORS . When I told the nurse what was happening, she rushed me to the trauma room where doctors and nurses encircled me. 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. 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. Epinephrine as Medication. Medication errors involving EPINEPHrine,* a high-alert drug, 1 are known to happen. Taxonomy of Patient Safety Medication Errors 1. 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. J Emerg Nurs 2013;39:151-3. ampoules and vials in storage areas. The concentration of epinephrine in those products may still be expressed as a ratio. Synthetic epinephrine is also used as a medication for the following: To stimulate the heart during a cardiac arrest; As a vasoconstrictor (medication â¦ Healthcare facilities could also consider the following in combination with higher leverage strategies to minimize these types of errors: Inhaled epinephrine may be used to improve the symptoms of croup. If preference cards are used, the circulating nurse should update any changes by initialing and dating the revision. In 11 (15.7%) cases involving high-alert medications, oxytocin was admin-istered instead of the prescribed medicationâ¦ Medications are sometimes listed on the preference card with options (e.g., if local, use medication âAâ; if general, use medication âBâ). Unfortunately, things were about to go terribly wrong. Response to: âMedication errors with push dose pressors in the emergency department and intensive care units Keywords: Epinephrine Anaphylaxis Medication error Amphastar has epinephrine available. It may also be used for asthma when other treatments are not effective. Epi label change will cut medication errors. Other facilities have implemented similar strategies (see Figure 2). 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 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. Studies show that labeling drugs through ratio expressions is inadequate and error-prone. errors showed that 180 (64.3%) reached the patient and 11 (3.9%) resulted in patient harm. â physician, hospital pharmacist, nurse â¢ Errors are possible at any step of the process. A factor associated with the epinephrine-related medication errors is its availability in different concentrations, namely 1:1,000 and 1:10,000. 6. To determine the most common errors of epinephrine administration during severe allergic-like contrast reaction management using high-fidelity simulation surrogates. Medication errors are a particular area of interest for me, so this paper caught my eyeâ¦.hereâs my summary of it. 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. In addition, 70 events (25%) involved high-alert medications, the majority of which were infusions. Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. Results. Errors with EPINEPHrine 1 mg ampuls or vials. There are several features related to epinephrine that increase the risk of errors in dosing and proper administration. Medication errors can occur in the absence of injury to the patient. Medication errors can result in death due to the use of high-dose epinephrine with parenteral administration.