Healthcare

Recent issue of Serious Medication Errors from the Institute for Safe Medication Practices (ISMP) and the American Society of Health-System Pharmacists said that a shortage of EPINEPHrine prefilled syringes may cause serious medication errors.

Although it is still unknown whether the EPINEPHrine shortage played any role in the fatal medication error, 1 hospital patient in Bangor, Maine, reported died from an overdose of EPHINEPHrine a few days before the alert was finalized.

Currently, EPINEPHrine emergency syringes 1 mg/10 mL (0.1 mg/mL) on back order from the sole manufacturer of this product until later this summer, creating risk for error.
The products of Injectable EPINEPHrine may not be safe alternatives for code carts both in emergency vehicles and other emergency needs but still available are 1 mg/mL in 1 mL ampuls or vials, 1 mg/mL in 30 mL vials, and 1 mg/10 mL (0.1 mg/mL) emergency syringes with an intracardiac needle.

Attempting to use it for intravenous or endotracheal administration with the needle attached or attempting to remove the needle could injure the patient as well as the caregiver because the 3.5-inch intracardiac needle is not removable and is incompatible with needless tubing systems.

Because EPINEPHrine is sensitive to air, light, and ph, with a short stability time when extemporaneously prepared, bulk compounding by pharmacy departments is not feasible.

By containing enough volume of drug to allow a 10-fold overdose, the 30-mL vial may more easily lead to an accidental overdose. Fatal events may occur when 1:1000 (1 mg/mL) and 1:10,000 (0.1 mg/mL) strength are confused.

The American Society of Health-System Pharmacists and ISMP issue an alert, which is distributed by the National Council on Medication Error Reporting and Prevention when ISMP’s Medication Error Reporting Program identifies a significant risk for serious or fatal errors.

The alert also provided recommendations to clinicians that should immediately implemented in order to prevent medication errors that could result from this situation caused by this drug shortage include bellow following;

- EPINEPHrine should be spelled with some Tall Man Letters to help prevent medication errors caused by look-alike drug names.
- Pharmacists should assess all areas where EPINEPHrine emergency syringes potentially may be used, including area emergency services and response teams, and they should educate clinicians regarding the shortage and recommend substitute products.
- Current supplies of EPINEPHrine emergency syringes should be conserved for code boxes and emergency responders (ie, for code situations in which pharmacists would not be present to dilute EPINEPHrine).
Pharmacists should also consider whether the number of syringes can be reduced to 2 per crash cart.
- Multiple-dose 30-mL vials of injectable EPINEPHrine 1 mg/mL should not stocked in code boxes because they closely resemble the 30-mL vials of topical EPINEPHrine, which may also be stocked in code boxes or used in the operating room.
- Intracardiac EPINEPHrine should have auxiliary labels warning against intravenous and endotracheal use and alerting practitioners to the danger of injury with attempted removal of the fixed needle. These syringes should also clearly be labeled “For Intracardiac Use Only.”
- When 1 mg/mL ampuls or vials are used instead of emergency syringes, the vial, diluent, and syringe label should be packaged in a clear plastic bag prominently labeled with the drug name and strength. Instructions should be included for preparing a dilution equivalent to a prefilled 1 mg/10 mL emergency syringe (ie, EPINEPHrine 1 mg – dilute in 9 mL of sodium chloride 0.9%).
- When ampuls or vials labeled as 1:1000 are substituted, a chart for converting doses in milligrams to milliliters should be provided, as well as instructions for preparing a dilution in code carts. These charts should be posted in areas where EPINEPHrine is often used.