Epi syringe shortage raises risk of fatal errors

Injections of the hormone epinephrine are used to treat life threatening allergic reactions to everything from bee stings to peanut or fish allergies. Epi, or adrenaline, is also used help restart the hearts of people suffering cardiac arrests.
Now a shortage of pre-dosed syringes has causes a spate of fatal or near fatal overdoses at hospitals across the country, according to Horsham, Pa.-based Institute for Safe Medication Practices. Because of the shortage of a product that has been commonly available since the 1970s, hospital personnel, as well as EMS first responders in ambulances need to mix their own.
ISMP notes that several studies show high error rates when people try to calculate epinephrine doses. “We are very concerned about patients being at risk of an error in dose calculation,” said ISMP president Michael R. Cohen.
On Wednesday, the nonprofit and the American Society of Health-System Pharmacists issued a national alert warning about errors such as on reported from Maine where a patient died on June 4 after getting 10 times the amount of epinephrine needed to treat an allergic reaction to seafood.  And in the April issue of the Annals of Emergency Medicine, ER doctors from St. John Hospital and Medical Center in Detroit reported on four patients who got “inappropriately higher doses” of epinephrine delivered through an IV (appropriate for treating cardiac arrest) rather than a shot to the muscles as needed for allergic reactions or anaphylaxis.
ISMP noted that the shortage of the pre-dosed syringes was expected to be resolved later this month, but still was concerned about the potential for errors resulting in avoidable patient injuries or deaths.
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