Medication Errors – Epinephrine

epiA number of years ago a young woman was driving along the road when a bee flew through her open window and stung her on the knee. She panicked. She was allergic to bees and she had left her epi-pen at home. She immediately pulled to the side of the road and dialed 911. A police officer arrived first and found her very anxious, but with no visible signs of a reaction. He helped her into the ambulance that arrived shortly thereafter, and then retuned to his cruiser to make arrangements for her car to be taken off the road. When he returned to the ambulance to give her the information about where to locate her car, he was startled to find the ambulance crew doing CPR on the young woman who within an hour would be pronounced dead at the hospital.

In medic school we are taught about medication safety. I personally don’t remember being taught about it, but don’t doubt that I was. It was after all almost twenty years ago. Maybe they didn’t have the 5 R’s then. Last year I graduated from nursing school, and I can tell you I had to know the 5 R’s. On my clinical exam if I did not do all and repeat them precisely, I would been sent home on the spot. Automatic failure.

The 5 R’s
Right patient
Right drug
Right dose
Right route
Right time.

With lots of verify and reverifying thrown in. Not to mention asking about allergies.

I can tell you, shame on me, that I don’t have a foolproof medication routine for the ambulance. Generally I reach for the drug I am going to give, look at the label, draw up the drug, and then give it.

Here are the drug mistakes I have made over the years (not counting errors of assessment);

I once gave Dramamine (Dimenhydrinate) when I meant to give Benadryl (diphenhydramine). (Both vials were the same size and color,and both had long names that began with D and both were right next to each other in the kit.

I have more than once in cardiac arrest situations, given epi when I meant to give atropine and vice versa. A fairly harmless mistake as I would be giving both drugs in multiple quantities during most arrests. (We break our boxes down so just the vials are next to each other all in a row. Eight epis and four atropines — the only way to tell them apart is to hold them up to your eyes and read them.) A mistake, nonetheless.

I gave 0.08 mg of narcan when I thought I had given 0.4 mg. Brain farted that my 1 cc syringe was a 3 cc. I ended up intubating a patient who soon thereafter yanked his own tube tube.

I gave ASA to someone allergic to Salisylates. I glanced at the W10 and not seeing ASA, went ahead and gave it to them. Only shortly thereafter did my brain realize I had seen Salisylates in the Allergy line. At the same time of my realization, the patient started to itch. Opps. I had to give them Benadryl.

I have never given Sodium Bicarb when I meant to give D50, but I have come close quite a number of times. Right next to each other, same size and color, just different print on the glass.

I have also, on very rare occasion, given expired drugs and hung expired fluids. That’s plain embarrassing. Not just plain emarrasing, truly embarrasing.

Granted a very small number of mistakes over 20 years of calls, but I and my patients have been lucky that I have not made more serious errors. Neither I nor my kit have been error-proofed.

People make mistakes and have brain farts. A good personal system can help you catch yourself when you fail. With a good external system can help you avoid even being in a position to make some errors.

Over the years the airline industry has become quite proficient at recognizing errors and then designing their systems to prevent them. EMS needs to do the same.

One of the most common and deadly errors is giving epi 1:1000 IV. This is what happened in the opening true life case. You can blame it all on the medic, but the system bears some responsibility. The medic did not seem to know that epi 1:1000 could be fatal when given IV. the medic did not seem to know that epi was not indicated if the patient was not showing any severe symptoms much less any symptoms. And the medic apparently did not know that the dose was 0.3 mg (SQ) rather than 1 mg. Perhaps in his mind, he thought. Patient allergic to bees, stung by a bee, doesn’t have epi-pen. I’m a medic. I have epi and I can get an IV so why don’t I just give it IV which is a quicker route than IM. And heck, why not just give a full milligram. I’m feeling generous. Clearly, the medic probably shouldn’t have even been practicing in the first place (tell me your system doesn’t have a few of these medics), and I believe he lost his medical control over this case, although I have heard that he is working somewhere else now as a medic.

Here is another case:

Young woman having a severe allergic reaction bordering on anaphylaxis, wheezing, itching hives. Medic draws up 50 mg of benadryl and 0.3 mg epi in separate 1 cc syringes. The medic is momentarily distracted by a family member. He picks up the syringe and injects the benadryl into the IV, no wait, he injected the epi. Oh shit. The patient grabs at her chest. “What did you give me!’” she screams. She has a run of VT, but it subsides. The medic reports the error, and the woman eventually is discharged without a problem.

These are not the only two times epi 1:1000 has been given IV. It is, in fact, a not uncommon error. Whether the medic is a fool or an excellent medic badly screwing up, the fact is the drug is right there in the kit waiting not just to save a life, but to take one.

A local clinic recently had a patient suffer an allergic reaction to bactrim. The doctor prescribed 0.3 mg epi. The nurse gave 0.3 mg epi 1:1000 IV. The patient went into cardiac arrest, but fortunately was revived and discharged from the hospital a few days later.

Hospitals are somewhat more advanced than EMS in how they deal with errors. Many enlightened hospitals try to adopt an approach similar to the airline industry. One local hospital, in response to nationwide errors, has removed epi 1:1000 from most areas of the hospital to be replaced by epi-pens. They are not the first hospital to do this.

epi-penThese actions are now filtering down to EMS, and we are considering requiring medics to use epi-pens as their first line approach to anaphylaxis. We will likely keep epi 1:1000 available on the rigs in a separate location so that it may be utilized in special circumstances (nebulized for croup, for bariatric patients, for infants too small for epi-pen juniors, for epi-pen failure, for epi ET if unable to get IO or IV).

Again, we would not be the first EMS service to do this.

The Use of Epinephrine in the Prehospital Setting

Along with this move, it is perhaps time to do some CMEs on medication safety as well as looking at our kits to see what possible errors could be made when a medic’s has a temporary lapse.

It’s all about risk versus benefit.

Remain Vigilant.

Do no harm.

And take care of the patient.

9 Comments

  • juliovenegas says:

    I used to work at a place that carried all the medication in old-style orange tackle boxes. Each drug had its own little tray, sometimes labeled–I kid you not–alphabetically.

    Everything drug that came in a vial except atropine and epi 1:10,000 was in alphabetical order. This led to more than a few medication errors when medics would pull a drug from the tray and not take the obviously-prudent step of looking at the vial. Versed (M for midazolam) was next to Zofran (O for ondansetron). Same size clear vial, same background on the label. The only obvious difference without reading it was the color of the text.

    Anyway, 5mg of midazolam does wonders for nausea and vomiting, but there was still the issue of folks not taking notice that their patient had abruptly decided to take a sonorous nap.

  • totwtytr says:

    That’s one reason why we don’t remove the prefilled syringes from their boxes.

    My partners and I always check each other, especially when it comes to drugs like Thiamine and Benadryl, which are easy to mistake. As are Atropine (although we don’t use vials any more) and Verapamil (which we don’t carry any longer).

    We’ve also started to use Epi Pens when we have to give epi to anaphylaxis patients. I think both the state and our service are a bit behind us on that one.

  • elin says:

    I was given adrenaline IV by mistake, had vt cardiac arrest and shocked back. Very luckily. I am so mad I am 34 have 2 small boys and was almost killed by a mistake.

  • Cole says:

    Interesting stuff, thanks for sharing. I always hear how bad epi 1:1000 is IV, but in the anecdotes above do you think 10mL of 1:10000 would’ve been any different than 1mL of 1:1000?
    Epi becomes so dilute once entering circulation that I doubt it makes much of a difference; the poison seems to be in the dose, not the concentration. Thoughts?

    • medicscribe says:

      Yes, from I have read the concentration can be quite harmful. That said, 1 mg of 1:10,000 can also be lethal. Any IV dose of epi outside of cardiac arrest, should be both diluted and pushed slowly. A drip is preferential.

  • David Farrar says:

    I just took 1ml of 1:1000 undiluted right in to my vein via the IV. But not added to the bag just pushed right in. Thought I was going to die. The ER took blood tests to determine there was no damage to my heart. It felt like death for two minutes. They said sorry they were supposed to give it to me in my leg muscle. What should I do now? I went home after two hours of monitoring. Any worries?

  • OB says:

    I can’t believe you were released after 2 hours 🙁
    I was in for 3 days after an accidental 1mg of 1:1000 given IV.
    I had an angiogram to check heart ok as my trop 1 levels were massively raised at 1940. Just out 2 days ago and the enormity of what happened is just settling.
    I’m very lucky all was ok I’m the end.

  • OB says:

    To add to my comment above…although slightly
    off subject…I’ve subsequently found out that post femoral angiogram I had a massive retroperitoneal bleed.
    No longer actively bleeding but lucky escape #3 in the space of 5 days. Maybe I should buy a lottery ticket!

  • Derek says:

    I dropped out of Med school as I couldn’t afford parking nevermind the rest which loans offered to pay for.

    I had obsessively studied medicine for 3 years, 12 hours a day. I built a lab for $2000 and started synthesizing my own drugs. Now, years later, members of my family come to me before consulting with a doctor and I generally just say what specialist they should see and what they should mention. In my short obsession, I saved 3 lives.

    But often while watching television like Game of Throne’s Geoffrey death scene, the adrenaline kicks in, and inside I’m screaming “He’s going into shock, I need x of y and z of w”. Can’t help it, even though I hate the dying character.

    Meanwhile my girlfriend lost her brother to asthma in 2008 because they lived in a poor area, didn’t have any adrenaline, and the EMTs didn’t arrive until 3 hours later. This combined with other realizations changed my life.

Leave a Reply

Your email address will not be published. Required fields are marked *