Epinephrine error

[katie4593]

Recently I witnessed a medication error with epinephrine, the patient was a 26 year old female, written for 0.5mg of epinephrine sq due to a allergic reaction to a medication, PT had hives/facial swelling. The patient was given 0.5mg of epinephrine 1:10,000 IV push. The patient for a few moments had sinus tachycardia, shortness of breath, chest pain, decreased vision & the feeling as if they were going to pass out. After a minute or so vitals were back to baseline & the patient only had complaints of a headache. Patient was admitted for observation, troponins/ekg were normal, echocardiogram was normal, also a Mri of the head was done as the patient had continued headache which was negative for any findings. My question is do epinephrine errors happen often? Also, I'm curious how this patient received such a high dose of epi but had no harm done, seems rare.....

[cleback]

Sounds like there are different schools of thought for administration and rationale, which all adds to the confusion.

I've seen epi given for allergic responses to medication. Even with a correct administration, the patients look like heck and need to be closely monitored.

[blondy2061h, MSN, RN]

If she got the correct dose in the wrong route it's certainly an error, but shouldn't be a life threatening one. The symptoms you describe, except the headache, are all side effects of epi and symptoms of an allergic reaction regardless.

[DowntheRiver]

As someone who has been consciously Epi'ed for an allergic reaction, I can tell you that the symptoms the patient experienced are typical. My chest hurt for about two minutes, my HR went up, my RR went up, I started sweating, and my head hurt for about 12 hours after.

[JKL33]

Why was the epi ordered as SQ when they had IV access? For what reason was the Epi being given?

It was given for "allergic reaction" as above. I've never given epi IV for that indication; it is given IM regardless of IV access or no IV access. I have seen adverse cardiac effects from the error described in the OP.

[Boomer MS, RN]

It was given for "allergic reaction" as above. I've never given epi IV for that indication; it is given IM regardless of IV access or no IV access. I have seen adverse cardiac effects from the error described in the OP.

For an allergic reaction, I always gave 0.2mg - 0.3mg epi SQ (not 0.5 mg) and never IV. Along with epi, solumedrol and benadryl were also ordered and given, the latter two IV. Patient with IV access and always on a monitor. This may be facility specific. Perhaps protocol for ICU patients, where MunoRN works, with severe allergic reactions is quite different.

[BedsideNurse]

I knew a really good ED nurse that accidentally gave epi IV instead of SQ and the pt had significant tachycardia, became acutely unstable and had an MI. It sucked and they felt awful. Giving epi IV instead of SQ is a not so uncommon error because as nurses we are often more familiar with code blue dosing and ACLS scenarios. Basically you need to make a mental note to always be careful with epi and do a double check with the MAR and have a another nurse look at what is ordered and what you are giving as a safeguard. It just takes a second. If a physician is giving a verbal order repeat it back to make sure you are clear on the dose and route. No one (with half a brain) will ever fault you for double checking epinephrine before giving it.

[MunoRN, RN]

It was given for "allergic reaction" as above. I've never given epi IV for that indication; it is given IM regardless of IV access or no IV access. I have seen adverse cardiac effects from the error described in the OP.

The OP's example was regarding SQ injection, which is not the preferred recommended route for anaphylaxis, IM is considered an appropriate alternative for IV particularly when given by someone not experienced with epinephrine or the ability to closely monitor the patient (or when there is no IV access). When given at the appropriate rate and with the appropriate monitoring, IV is more predictable and better facilitates avoiding giving an excessive dose.

Appropriate route of administration of epinephrine

[Boomer MS, RN]

The OP's example was regarding SQ injection, which is not the preferred recommended route for anaphylaxis, IM is considered an appropriate alternative for IV particularly when given by someone not experienced with epinephrine or the ability to closely monitor the patient (or when there is no IV access). When given at the appropriate rate and with the appropriate monitoring, IV is more predictable and better facilitates avoiding giving an excessive dose.

Appropriate route of administration of epinephrine

Thank you, MunoRN, for this information. My experience was based on two EDs at Level I academic centers and one community ED. All three followed that recipe I described for an allergic reaction. If more than Epi is given for an allergic reaction, it is difficult to determine which drug, the epi, solumedrol or the benedryl, has the greatest effect based on different mechanisms. As you know, practice guidelines change often. Interesting discussion.

[Rocknurse, MSN, APRN, NP]

Luckily for her the half life of epi is short and so the effect passes quite quickly. The rule of thumb should be that if one is unsure of any med they are about to give, that they place a call to pharmacy to doublecheck. I've seen a lady with an IV gtt that was completely at the wrong dose for HOURS and she was exhibiting severe symptoms that seemingly went unnoticed until I picked up the patient. Even while I was getting report I could see something was wrong and I ended up calling a code. Unfortunately she died. She was young...in her 20s, with a newborn and a toddler. I'll never forget that lady. Pressors are deadly. If you don't know what you're doing....ask.

[JKL33]

The OP's example was regarding SQ injection, which is not the preferred recommended route for anaphylaxis, IM is considered an appropriate alternative for IV particularly when given by someone not experienced with epinephrine or the ability to closely monitor the patient (or when there is no IV access). When given at the appropriate rate and with the appropriate monitoring, IV is more predictable and better facilitates avoiding giving an excessive dose.

Appropriate route of administration of epinephrine

Hi, Muno -

Thanks for the link. I understand IM vs SQ - we haven't given it SQ for a long time. As for the IV portion, I will need to look into it more. I hate to sound like I'm just arguing, but the question is, when someone walks into an ED in the condition described in the OP, is that considered "cardiovascular collapse". No, it isn't....so my inclination is that IV epinephrine is not indicated. There is a risk-benefit analysis that still must take place. In the setting of actual cardiovascular collapse, that risk-benefit of IV epi makes much more sense. This particular link mentions IV epi in what would essentially be a code situation - - CV collapse while under anesthesia.

This is our current thinking in the ED anyway. I can't see it changing any time soon.... I too have seen persistent STEMI-like EKGs with this error....

[SafetyNurse1968, ADN, BSN, MSN, PhD]

The ISMP website identifies Epinephrine as one of the tops drugs involved in medication errors: Institutional High-Alert Medications.

I am sure you know this, but please take the time to report the error here: Report Medication Error To ISMP

it helps support patient safety - we have to report everything so we have data to prevent future error.

[bgxyrnf, MSN, RN]

Normally SQ epinephrine dosage strength is 1:1,000...this patient was given 1:10,000 epinephrine which is reserved for cardiac resuscitation. Giving epi IV vs SQ is very very different & usually results in harm to the patient. After I witnessed this event I research articles online and most people that were given IV Epi accidentally instead of sq/IM suffered from severe cardiac arrhythmias/reduction in EF, etc. I guess this patient just got lucky

Anaphylaxis is also and indication for IV epinephrine, 1:10,000 -- albeit in lower doses than cardiac (0.1 to 0.4) and generally given as a slow push.

Appropriately administered, it generally does not cause harm to the patient.