Case on Medication Error: Right Drug, Wrong Route

A 40-year-old female was brought into the ER for shortness of breath and rash following ingestion of seafood. On presentation, she was found to have edema of the throat with a mild stridor upon inspiration. Her temperature was 98.7°F
with a blood pressure of 100/69 mm Hg and a pulse of 70 bpm. The patient was placed on supplemental oxygen and a 0.5 mg (1:1000) dose of epinephrine was ordered. Shortly following IV infusion of the epinephrine, the patient complained of chest pains on her left side with tingling in her fingertips. ECG showed ST elevation and elevation of her serum creatine kinase levels consistent with a myocardial infarction. She was given 2 doses of 0.4 mg sublingual nitroglycerin over the next 10 minutes until her heart rate and blood pressure declined towards normal. A subsequent ECG indicated her ST levels had returned to baseline. Investigation of this incident determined that while 0.5 mg 1:1000 dose of epinephrine was ordered, the route of administration was not specified and the patient incorrectly received the epinephrine IV instead of IM.

In the patient highlighted in this case, instead of the standard IM injection of epinephrine for anaphylaxis, the patient received an IV dose of epinephrine, which is normally reserved for patients with a myocardial infarction. A medical error is defined as a preventable adverse event caused by the failure of an action to be completed or use of the wrong action that results in injury or death of a patient. Medical errors are responsible for injury in 1 out of every 25 hospital patients and result in more deaths than those caused by car accidents, breast cancer, or AIDS individually.1 Consequences of medical errors include 2.4 million extra hospital days and increased costs of approximately $17-$29 billion/year.1 Medical errors can occur in various areas of the health care system including medication errors, diagnostic errors, and surgical errors. In addition, multiple factors, such as communication errors and equipment failure, can affect the occurrence and severity of medical error.

Approximately 25% of all drug-related injuries are preventable.2 Of the 4 billion prescriptions filled each year, more that 50 million errors related to these prescriptions also occur.2 Medication-related errors can occur anywhere within the prescription process, from illegible physician handwriting to inaccurate transcription and improper administration. Common causes associated with medication errors are listed in Table 1.3
Table 1: Causes of Medication Errors
Miscommunication of prescriptions due to:
  • Illegible handwriting
  • Use of "inappropriate" abbreviations
  • Look/sound-alike drug names (eg, ephedrine and epinephrine
  • Leading and trailing zeroes
  • Incomplete orders
Lack of information
  • About drug
  • About patient
Dispensing errors
  • Dosing miscalculations
Administration errors
Transcription errors
Failure to follow proper procedure
  • Not double checking right drug, right dose, right route, right time, right patient
Epinephrine is a catecholamine that stimulates alpha (α), beta 1 (β-1), and beta 2 (β-2) adrenergic effector cells in a dose-dependent manner. Epinephrine exerts its effects on heart, vascular, and other smooth muscles and is indicated for both anaphylaxis and myocardial infarction. It is available in several different concentrations and doses, and is administered by varying routes specific to each indication (Table 2).
Table 2: Epinephrine Doses Based on Indication4,5
Indication Dose Administration
Anaphylaxis 0.3-0.5 mg of 1:1,000 concentration Intramuscular (IM)
Anaphylactic shock 0.1 mg of 1:10,000 concentration Slow intravenous (IV) over 5 minutes
Myocardial infarction 1 mg of 1:10,000 concentration IV push
There are several features related to epinephrine that increase the risk of errors in dosing and proper administration. The dose of epinephrine used for a heart attack is much higher than the dose used for anaphylaxis. A factor associated with the epinephrine-related medication errors is its availability in different concentrations, namely 1:1,000 and 1:10,000. Doctors, nurses, and pharmacists must be aware of the various concentrations, what these concentrations mean, and which concentration is appropriate for specific situations. There is also the possibility of misreading the concentration because of all the zeros.
Most heart attacks and anaphylactic reactions are treated under emergency conditions where misreading of labels and concentrations can occur. Furthermore, accidental overdoses can be a result of miscommunication between health care professionals, inadequate knowledge of appropriate dosing, and miscalculation of doses.
While prefilled syringes can help to reduce the confusion surrounding epinephrine, they can also create further confusion. The concentrations of injectable epinephrine may be given as a measurement of their mass (eg, mg or mg/mL) instead of the ratios (eg, 1:1,000) many health care providers may be accustomed to. These differences may not be understood or even recognized in an emergency situation. Further, a crash cart could theoretically contain 2 different prefilled syringes, one for IM and another for IV administration, at different concentrations, thereby creating another chance for a misstep.
The Agency for Healthcare Research and Quality (ARHQ) developed a list of "never events" which identified events within health care that should "never" happen. Among them was that medication errors should never lead to death or disability. And while a medication error was the main topic in the case presented, neither death nor a serious disability was the outcome. However, the health care system as a whole and on an individual institute basis has been working to create a safer environment for patients.
Many improvements utilized today incorporate information technology and computers. Hospitals are utilizing computerized physician order entry (CPOE) which can check for drug-drug interactions, allergies, multiple doses, or incorrect drug orders and can help to reduce redundancies and medication errors.6 Also being incorporated are clinical decision support systems (CDSS) which are software that link individual patients to a computerized knowledge base to create a patient-specific diagnosis or care plan. One function of CDSS is to send computer-generated reminders to hospital staff to ensure that standard protocols or guidelines are being properly followed.6 In addition to all of these IT interventions, the incorporation of an electronic bar code system and electronic medical records (EMRs) have also been shown to reduce hospital medication errors.6
As even computers and electronics are not infallible, and power outages have been known to occur, health care professionals need to maintain an awareness of their actions and common errors that may occur. One study found that by including pharmacists on clinical rounds helped to reduce medication errors by 78%.7 Medication errors can occur at any step in the prescription process, but these errors can be avoided or reduced if everyone takes an active role in their prevention. 

  1. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health System. Institute of Medicine: Washington, DC; 2000.
  2. Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
  3. Cohen RM. Causes of medication errors. In: Cohen RM, ed. Medication Errors: Causes, Prevention, and Risk Management. Sudbury, MA: Jones and Bartlett Publishers; 2000:1.1-1.8.
  4. The diagnosis and management of anaphylaxis: An updated practice parameter. JAllergy Clin Immunol. 2005;115:S483-S523.
  5. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7.2: Management of cardiac arrest. Circ. 2005;112:IV58-IV66.
  6. Menachemi N, Brooks RG. Reviewing the benefits and costs of electronic health records and associated patient safety technologies. J Med Syst. 2006;30:159-168.
  7. Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163:2014-2018.