Webinar

Prevent the Inadvertent Injection of Epinephrine Intended for Topical Use:
An Operating Room Safety Initiative.

Wednesday, June 23, 2010 at 12 noon EST

ISMP Canada urges all facilities that perform ENT procedures requiring the use of concentrated epinephrine for topical application to review their processes and take the necessary steps to prevent it from inadvertently being injected (infiltrated). ISMP Canada has received several reports of incidents involving the inadvertent injection of concentrated epinephrine 1 mg/mL (1:1000) for topical use instead of the intended local anesthetic with dilute epinephrine (e.g., 0.01 mg/mL or 1:100,000; and 0.005 mg/mL or 1:200,000), leading to harm and death.

This one-hour webinar will focus on sharing information and learning from medication incidents involving the inadvertent injection of concentrated epinephrine 1 mg/mL to help improve patient safety and quality of care across Canada.

Learning Objectives:

At the end of this session, participants will be aware of:

• the underlying factors that have led to the inadvertent injection of concentrated epinephrine 1 mg/mL intended for topical use during ENT procedures;
• critical steps and potential failure points with the use of concentrated epinephrine for topical administration; and
• strategies other organizations have implemented to reduce risk.

Contact Us: webinars@ismp-canada.org

Speakers

Christine Koczmara, RN, BSc Christine is a senior analyst at ISMP Canada who has over 15 years nursing experience, including critical care. At ISMP Canada she is involved with medication incident analysis, providing expertise to projects such as the removal of concentrated potassium chloride, enhancing opioid safety, and enhancing safety with unfractionated heparin through the Ontario Medication Safety Support Service. Christine has a lead role in the coordination of and publication of the ISMP Canada Safety Bulletin, in addition to writing journal articles focusing on medication safety.

Cathy Isman, RN, BScN, CPN(C) Cathy is a nurse consultant for ISMP Canada focusing on enhancing safety perioperative medication safety. Cathy has over 20 years experience in perioperative nursing with the last number of years dedicated to surgical clinical education. Cathy also holds a position at Centennial College as a lecturer and supervisor of the perioperative program.

Background

Two ISMP Canada Safety Bulletins highlight mix-ups between concentrated epinephrine 1 mg/mL for topical use and local anesthetics with dilute epinephrine for infiltration during ENT procedures. These incidents have also been reported internationally. ISMP US has previously published reports of such mix ups, including the death of a 7-year old child during ear surgery. A survey conducted by the American Academy of Otolaryngology - Head and Neck Surgery indicates 68.9% of respondents are concerned about a potential mix-up in the administration of concentrated epinephrine during surgery; furthermore, 27% of respondents had experienced or heard of this misadministration occurring. The Food and Drug Administration in the US recently posted safety information that highlights 2 cases as well as recommendations from the 2009 ISMP Canada Safety Bulletin.

Related Links:

ISMP Canada Safety Bulletins:

• ALERT: Fatal Outcome after Inadvertent Injection of Epinephrine Intended for Topical Use
• Risk of Tragic Error Continues in Operating Rooms

• Free to Ontario hospitals – funded by the Ontario Ministry of Health and Long-Term Care

• Case update: epinephrine death in Florida
• Fatal outcome after inadvertent injection of topical epinephrine

• FDA safety Alert
• FDA video

Contact Information