Drug Alert Warns Epinephrine Syringe Shortage Could Lead to Dosing Error Risks

In yesterday’s blog, our medication error attorneys discussed a recent accidental overdose of epinephrine that led to a man’s death in a hospital. According to the FDA, Epinephrine is a high alert medication that could cause significant patient harm or injury when used in error. Medication error can occur when there is confusion in regard to epinephrine product ratio strengths. The Institute for Safe Medication Practices, ISMP, has received a number of fatality reports due to miscalculations of strengths of epinephrine injections.

In similar epinephrine news, the Institute for Safe Medication Practices (ISMP), and the American Society of Health-System Pharmacists (ASHP), announced a National Alert Network (NAN) message this month, to warn healthcare providers about dangerous medication mistakes that could be caused by a shortage of pre-filled epinephrine syringes.

The NAN warning states that emergency syringes of epinephrine in 1mg/10mL (0.1 mg/ml) are currently on backorder from the Hospira Inc., the only manufacturer of the product after the pharmaceutical company Amphastar stopped making its emergency syringes of the drug in 2009.

According to ASHP’s director of medication use, quality and improvement, Bona Benjamin, Epinephrine is a life saving drug used in ambulances, hospitals and any other emergency settings when a patient’s heart has stopped.

Benjamin claimed that the shortage of epinephrine does not effect quantities of the EpiPen, the epinephrine injection products that are self administered in .3 mg and .15 mg doses, to remedy severe emergency reactions to food, medication, insect bites, and other reactions of an allergic nature.

The American Academy of Family Physicians (AAFP) reports that injectable epinephrine is still available as 1mg/mL in 1-mL vials and as 1 mg/mL in 30-mL vials, and also as emergency drug syringes with intracardiac needles, but both organizations caution that those drug products might not be suitable or safe replacement alternatives for emergency vehicles, code carts, or other needs or emergencies. NAN warns health care professionals to be aware of the potential for medication errors that could happen as a result of the shortage—in terms of compatibility of products, drug strengths, drug substitution, diluting the drug, and miscalculations that could lead to patient injury, overdose, or even wrongful death.

In Maryland and the Washington D.C.-area, contact Lebowitz and Mzhen, LLC today.

Shortage of Prefilled Epinephrine Syringes Raises Dosing Error Risk, The American Academy of Family Physicians (AAFP), July 2, 2010
EPINEPHrine pre-filled Syringe Shortage, National Alert Network Message from the American Society of Health-System Pharmacists/Institute for Safe Medication Practices, June 16, 2010

Related Web Resources:

U.S. Food and Drug Administration: Medication Error Reports
Institute for Safe Medication Practices, (ISMP)

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