NAN Alert: Potential for Serious or Fatal Errors Due to Epinephrine Shortage

June 23, 2010 4:00 PM

The National Alert Network (NAN) for Serious Medication Errors was activated on June 16, 2010, for an urgent message on the potential for serious or fatal errors with epinephrine due to a shortage of emergency syringes. As epinephrine emergency syringes 1 mg/10 mL are currently on backorder, the NAN advises health care providers of various errors that may occur with the use of alternative injectable epinephrine products. The message also advises pharmacists to evaluate all potential areas where epinephrine emergency syringes are used, including area emergency services and response teams, and communicate information about the shortage and recommended substitute products. Additional specific recommendations are included in the alert.

While it has not been linked to the shortage, a fatal medication error with epinephrine was reported just before the alert was finalized, as noted by the National Council on Medication Error Reporting and Prevention (NCCMERP). NCCMERP stressed that while the Institute for Safe Medication Practices and American Society of Health-System Pharmacists had no prior knowledge of the event, the error reinforces the importance of the safety precautions included in the alert. According to the Bangor Daily News, the fatal error involving epinephrine occurred at the Mayo Regional Hospital in Dover-Foxcroft, ME, and the cause of the error is unknown.