Patient Deaths from Injection of Topical Epinephrine

The Institute for Safe Medication Practices (ISMP) recently cited a report from the ISMP Canada Safety Bulletin about the death of a patient who was accidentally injected with topical epinephrine. The attending surgeon and nurse mistakenly thought the syringe they were using contained lidocaine with epinephrine 1:100,000.

ISMP noted an earlier case in which a child died from cardiac arrest after his ear was infiltrated with a syringe containing epinephrine 1:1,000 that had been filled from an open cup. The physician mistakenly assumed that the solution in the cup contained lidocaine with epinephrine 1:100,000.

ISMP recommends several steps that can help prevent fatal accidents of this kind, including:

•Supply epinephrine for topical use in a pour-bottle so that it is not likely to be injected. If these bottles are not available from the manufacturer, require the pharmacy to prepare ready-to-use doses in pour bottles or topical syringes.

•Never withdraw a topical medication into a parenteral syringe and, conversely, do not place a solution intended for injection, such as a local anesthetic, into an open container.

•Be sure that the word "topical" appears on any container holding a solution intended for topical use.

•Keep local anesthetics for injection in their original vials until they are going to be used. Then withdraw the medication into a syringe and label it immediately.

•And if possible, prepare pledgets of topical epinephrine before each procedure, which can eliminate the need for topical epinephrine in vials.

FDA Patient Safety News: September 2009

For more information, please see our website:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=90#10

Category:

Education

Tags:

• Epinephrine
• medication error
• FDA
• topical
• mix-up