Medication errors involving EPINEPHrine,* a high-alert drug,¹ are known to happen. An article in the September 2006 issue of the Patient Safety Advisory focused on two problems indicated in reports submitted through the Pennsylvania Patient Safety Authority’s reporting system and elsewhere: (1) concentration expressed as a ratio strength rather than a metric per-volume concentration and (2) confusion between EPINEPHrine and ePHEDrine.² Since September 2006, Pennsylvania facilities have continued to report events involving EPINEPHrine. Ongoing individual case review and analysis indicated that a number of different types of errors were occurring with EPINEPHrine, many with a potential to cause patient harm. Authority analysts decided to look again into the nature of EPINEPHrine events and provide an updated picture of what is going wrong, beyond just name and concentration confusion.

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* The “TALLman” (or mixed case) lettering schemes suggested by the Institute for Safe Medication Practices³ for the look-alike names EPINEPHrine and ePHEDrine are used in this article. TALLman letters, by drawing attention to the dissimilarities in the names, can help distinguish similar looking drug names⁴ and make them less prone to mix-ups.^5,6
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Analysts examined all medication and medical error reports that included mention of EPINEPHrine (n = 648) that were submitted to the Authority from June 2004 to July 2009. Review of the cases found that 280 reports indicated some type of error occurred involving EPINEPHrine. The majority (268 of 280) were classified as some type of medication error. The other 12 EPINEPHrine-related events were classified as an error related to procedure/treatment/test, complication of procedure/treatment/test, or other/miscellaneous.

Analysis of the events filtered by “harm” showed that more than half the errors involving EPINEPHrine resulted in a need for monitoring, intervention, and/or treatment (see Table 1). Nearly 11% (30 of 280) of the reports indicated that some level of patient harm, including permanent harm or a near-death event, occurred. Patients required either monitoring to confirm that no harm occurred or intervention to prevent harm in 45% (126 of 280) of the reports.

  Table 1. Harm Scores of Reported Events 

 

The largest percentage of events (26.8%) occurred in the emergency department (ED) (see Table 2). The events in the ED also accounted for the highest number of harmful events. Thirteen of the 30 patients harmed as a result of an error involving EPINEPHrine were being treated in the ED at the time of the event.

  Table 2. Top 10 Cited Locations of Events as Reported by
  Pennsylvania Facilities (Total Reports N = 280)

More events were classified by facilities as wrong-route errors (59) than as any other error type (see Table 3). Typically, these events involved intravenous (IV) administration of EPINEPHrine, rather than subcutaneous or intramuscular administration, leading to cardiovascular sequelae (e.g., elevated blood pressure, increased heart rate, chest pain). However, analysis of the error descriptions in the reports identified 12 additional reports that described wrong-route events but were not classified as such. This increased the number of wrong-route errors to 71, or 25.4% of all EPINEPHrine-related events. This analysis also revealed that wrong-route errors accounted for 63.3% of the harmful events (19 of 30), more than any other type of error.

  Table 3. Top 10 Reported Error Types as Reported by
  Pennsylvania Facilities (Total Reports N = 280) 

When looking specifically at reports from the ED, 41 of the events in the ED were classified by facilities as wrong-route errors. Analysis of error descriptions identified six additional cases of wrong-route events that had been classified using other error types. As a result, the number of wrong-route errors in the ED rose to 47 or 62.7% of the ED events.

Wrong drug was the second most commonly cited medication error type (17.9%). Analysis of the events not classified as a type of medication error uncovered one additional case, raising the total number of wrong-drug events to 51. These errors involved mix-ups of EPINEPHrine with medications such as ePHEDrine (n = 6), norepinephrine (n = 8), neosynephrine (n = 5), and Ethamolin® (n = 3). Wrong-drug errors accounted for only two cases of patient harm. However, the inadvertent IV administration of EPINEPHrine instead of ePHEDrine resulted in a near-death event for a patient on a labor/delivery/recovery unit.

Thirty-one events were classified as wrong dose/over dosage. While this event type was fourth among the most commonly cited event types, it accounted for the second most number of harm events (5). Many of these events involved pump-related errors (e.g., programming) or administration of more volume of drug than necessary.

Ratio-strength expressions have been known to create confusion and lead to errors.^2,7 Practitioners have not recognized or understood the difference between dose concentrations, such as 1:1,000 (or 1 mg/mL) and 1:10,000 (or 0.1 mg/mL). Also, numbers in the thousands are easy to confuse because there are so many zeros (i.e., 1,000 looks like 10,000). Given their error-prone nature, the Authority’s reporting system database was examined specifically for cases of confusion related to the use of ratios to express concentration. For the majority of event reports, insufficient information was provided to determine the role, if any, the ratio expression played. However, eight cases were identified. The events were classified as either wrong dose/over dosage or wrong strength/concentration errors. Four of these events resulted in temporary harm that required either treatment/intervention or initial/prolonged hospitalization.

Given the potential harm associated with an error that occurs with the use of EPINEPHrine, facilities should examine how and where the drug is ordered, stored, and administered. Particular attention should be focused on practices in the ED as well as strategies to prevent wrong-route errors because these areas/errors are affecting the most patients and inflicting the most harm. For additional strategies, review the September 2006 Patient Safety Advisory article “Let’s Stop This “Epi”demic!—Preventing Errors with Epinephrine.”

Notes

1. Institute for Safe Medication Practices (ISMP). ISMP 2007 survey on high-alert medications: differences between nursing and pharmacy perspectives still prevalent. ISMP Med Saf Alert [online]. 2007 May 17 [cited 2009 Jul 20]. Available from Internet: http://www.ismp.org/Newsletters/acutecare/articles/20070517.asp.
2. Let’s stop this “Epi”demic!—preventing errors with epinephrine. PA PSRS Patient Saf Advis [online] 2006 Sep [cited 2009 Jul 20]. Available from Internet: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3)/
   Pages/16.aspx.
3. Institute for Safe Medication Practices. Use of tall man letters is gaining wide acceptance. ISMP Med Saf Alert [online]. 2008 Jul 31 [cited 2009 Jul 20]. Available from Internet: http://www.ismp.org/Newsletters/acutecare/articles/20080731.asp.
4. Filik R, Purdy K, Gale A, et al. Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data. Soc Sci Med 2004 Dec; 59(12):2597-601.
5. Filik R, Purdy K, Gale A, et al. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors 2006 Spring;48(1):39-47.
6. Grasha A. Cognitive systems perspective on human performance in the pharmacy: implications for accuracy, effectiveness, and job satisfaction. Report No. 062100. Alexandria (VA): National Association of Chain Drug Stores (NACDS); 2000.
7. Institute for Safe Medication Practices. It doesn’t pay to play the percentages. ISMP Med Saf Alert [online]. 2002 Oct 16 [cited 2009 Jul 20]. Available from Internet: http://www.ismp.org/Newsletters/acutecare/articles/20021016.asp.