Read about how to lower the risk of wrong-route epinephrine errors when treating severe allergic reactions. Also in this issue: how patients and providers can improve health literacy, raising awareness of the dangers of energy drinks, and more.
Please share this information with your contacts to ensure everyone has the knowledge and tools to help keep safe.
Wrong-Route Errors Associated With Epinephrine to Treat Severe Type I Allergic Reactions
The Patient Safety Authority has received multiple reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing wrong-route errors with epinephrine intended to treat anaphylaxis and other severe type I allergic reactions, in which epinephrine was incorrectly ordered and/or administered by the intravenous route instead of the intended intramuscular route. We previously identified wrong-route errors as the most frequent error type involving epinephrine.1,2 Despite our published analyses and mitigation strategies,1-3 we continue to receive PA-PSRS reports describing wrong-route errors with epinephrine to treat severe type I allergic reactions.
Epinephrine is a nonselective alpha- and beta- adrenergic agonist with various indications and routes of administration.4,5 One of the indications for the use of epinephrine is the treatment of severe type I allergic reactions, including anaphylaxis. Administration of epinephrine for this indication is typically given by the intramuscular or subcutaneous route,4 with the intramuscular administration in the thigh preferred and shown to provide the highest peak blood levels.6,7 Intravenous bolus administrations of epinephrine are generally reserved for life-threatening situations such as cardiac arrest due to asystole or pulseless electrical activity.5,8 According to PA-PSRS reports, patients have experienced several adverse effects following erroneous intravenous administrations of epinephrine to treat type I allergic reactions, including sudden rise in blood pressure, electrocardiogram (EKG) changes such as ventricular tachycardia and atrial fibrillation with rapid ventricular response, “excruciating pain” and feeling of “going to die,” as well as transfer to a higher level of care.
Erroneously administered intravenous doses of epinephrine have been associated with several factors based on PA-PSRS reports, including verbal orders, lack of scanning prior to medication administration, rapid response situations, formulary change from the use of autoinjectors to the use of vials, and confusing electronic orders that lack clear and simple instructions for the route of administration. Another noteworthy aspect identified in the PA-PSRS reports is that several medications used to treat allergic reactions, such as steroids, diphenhydramine, and even famotidine, are typically administered intravenously and at the same time as epinephrine.
Facilities can mitigate the risk of wrong-route epinephrine errors by implementing the following safety strategies.
- Use autoinjectors, which are designed to deliver premeasured single doses of epinephrine by the intramuscular or subcutaneous route.2,3,9-11
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If not using autoinjectors, create an anaphylaxis kit that contains the vials or ampules of epinephrine, needles intended for intramuscular administration, auxiliary labels, clear instructions, and other necessary supplies.9,11
- Store epinephrine products used to treat anaphylaxis separately from those intended for resuscitation carts.10
- Ensure that the order is clear, concise, and easy to understand. Do not refer to epinephrine concentrations using ratios. The U.S. Food and Drug Administration (FDA) currently requires the labeling of epinephrine strengths in amount per volume (e.g., milligrams per milliliter [mg/mL]) instead of ratio expressions (e.g., 1:1000).12
- Distinguish the separate epinephrine orders for different indications, and ensure that the routes of administration are clearly visible.13
- Create a warning in the automated dispensing cabinet to remind the user of the intended route of administration, and, if applicable, consider affixing auxiliary labels on the top of the cubby.13
- Limit the use of verbal orders to urgent situations. Create and reevaluate facility guidelines to establish standardized processes for verbal orders, such as the readback method, to confirm the route of administration.9,10
- Follow proper protocol in labeling and scanning the medication prior to administration.13
Watch & Share: Nourishing Health Literacy: How to Serve Up Better Understanding
Healthcare providers in Pennsylvania play an important role in ensuring patients have the knowledge they require to make informed decisions. Effectively communicating appropriate details while addressing each patient’s unique needs and concerns remains a challenge for both providers and patients.
The team defines health literacy, describes the scope and implications of the problem, identifies the barriers that patients and providers have when trying to address low health literacy, and outlines strategies to improve health literacy.
From the Pages of Patient Safety
Caffeinated Energy Drinks and Supplements: A Wake-Up Call for Consumers and Healthcare Providers
How much caffeine have you had today? Are you sure? If you start your mornings with a cup of coffee (about 95 milligrams of caffeine), you probably don’t have much to worry about, but if you also consume energy drinks or supplements, you should pay attention to their ingredients.
In general, healthy adults shouldn’t have more than 400 mg of caffeine a day, but energy drinks contain anywhere from 100 to 300 mg. What’s the risk? Taking in a lot of caffeine in a short period could result in acute caffeine intoxication and symptoms like anxiety, restlessness, sleeplessness, elevated heart rate, tremors, and nausea. Severe overdoses can cause potentially fatal heart problems or seizures. Also be careful of highly caffeinated beverages, which may not prominently advertise their caffeine content, and be aware of potential interactions with medications, recreational drugs, and existing health conditions. Healthcare providers can take an active role in informing their patients about safe energy drink use.
Lessons From Event Reports
Diabetes Task Force Improves Care
At one facility, over a few months several incidents occurred involving patients in diabetic ketoacidosis (DKA), a life-threatening complication in which too much acid (ketones) builds up in the blood, in both the emergency department and acute care. The root cause analysis team assembled a diabetes task force to address the causes and concerns around care of diabetic patients and those in DKA. The task force, consisting of registered nurse supervisors, risk managers, the directors of Information Technology and acute care services, a diabetes educator, and the ED medical director, met over six months and implemented changes, including reviewing, revising, and creating new diabetes order sets; reviewing, revising, and creating new policies; and educating nurses and physicians of these changes. As a result of these collaborative improvements and other task force initiatives, no new incidents have occurred in the management of diabetes and DKA.
