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Errors with Concentrated Epinephrine in Otolaryngology

Authors

  • Rahul K. Shah MD, FAAP,

    Corresponding author
    1. Division of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine, Washington DC, U.S.A.
    • Rahul K. Shah, MD, FAAP, Division of Otolaryngology, Children's National Medical Center, 111 Michigan Avenue, NW, Washington DC 20010, U.S.A.
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  • Elizabeth Hoy MHA,

    1. Assistant Director of Regulatory Affairs and Quality Improvement, American College of Surgeons, Washington DC, U.S.A.
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  • David W. Roberson MD, FACS,

    1. Department of Otolaryngology and Communication Enhancement, Children's Hospital Boston, Boston, Massachusetts, U.S.A.
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  • David Nielsen MD

    1. American Academy of Otolaryngology - Head and Neck Surgery, Alexandria, Virginia, U.S.A.
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  • Presented at the Triological Society Annual Meeting, May 4th, 2008, Orlando, FL.

Abstract

Objectives: Obtain data on errors and adverse events with concentrated epinephrine in otolaryngology.

Project Design: Anonymous survey.

Methods: Confidential, voluntary, and online survey of Academy members.

Results: One hundred twenty-six surveys were completed. The average length of practice of respondents was 19.6 years (range 1–43 years, SD 9.37 years). In the past year, 16 (12.7%) respondents experienced a problem with misadministration of concentrated epinephrine; 18 (16.4%) additional respondents heard of such an error. Fourteen respondents noted adverse outcomes from these instances, including five mortalities. About 68.9% of respondents are concerned about a potential mix-up in the administration of concentrated epinephrine during surgery. Forty-eight respondents reported experiencing an error in their career (average 2.5, SD 4.52, range 1–30 instances).

Conclusions: Otolaryngologists are vulnerable to errors in the administration of concentrated epinephrine. Academy members are concerned about preventing these high risk errors. We recommend double checking epinephrine dilution before administration. We also encourage all physicians using concentrated epinephrine to participate in development, implementation, and training insystems to reduce the potential for misadministration ofepinephrine. Hospitals, free standing outpatient surgery centers, and regulatory bodies should consider forcing mechanisms and redundant systems to reduce inadvertent administration of concentrated epinephrine.

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