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Surgical Correction for Pediatric Epiblepharon and Trichiasis
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Errors with concentrated epinephrine in otolaryngology.

Rahul K Shah1, Elizabeth Hoy, David W Roberson

  • 1Division of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC 20010, USA. banuandrahul@aol.com

The Laryngoscope
|August 13, 2008
PubMed
Summary

Otolaryngologists report errors and adverse events with concentrated epinephrine administration, including mortalities. Double-checking dilutions and implementing safety systems are recommended to prevent these high-risk medication errors.

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Area of Science:

  • Medical Safety
  • Otolaryngology
  • Pharmacology

Background:

  • Concentrated epinephrine is used in otolaryngology.
  • Medication errors, particularly with concentrated epinephrine, pose significant risks.

Purpose of the Study:

  • To gather data on errors and adverse events associated with concentrated epinephrine in otolaryngology.
  • To assess otolaryngologists' concerns regarding epinephrine administration errors.

Main Methods:

  • An anonymous, confidential, and voluntary online survey was distributed to Academy members.
  • The survey collected data on past experiences with concentrated epinephrine misadministration and associated outcomes.

Main Results:

  • 12.7% of respondents reported misadministration errors in the past year; 16.4% heard of such errors.
  • 16.4% of respondents reported adverse outcomes, including five mortalities.
  • 68.9% of otolaryngologists expressed concern about potential epinephrine mix-ups during surgery.

Conclusions:

  • Otolaryngologists are susceptible to errors in concentrated epinephrine administration.
  • Recommendations include double-checking epinephrine dilutions and developing robust safety systems.
  • Hospitals and regulatory bodies should implement redundant systems to prevent inadvertent administration.