Description of Event or Problem · 0
AN UNRESPONSIVE, COLD TO THE TOUCH INFANT WAS BROUGHT TO THE EMERGENCY DEPARTMENT AND A CODE WAS CALLED. THE PHARMACIST RESPONDED TO THE CODE AND WAS ASKED TO DRAW UP EPINEPHRINE FOR IV USE USING THE RED SECTION OF THE BRESLOW TAPE. THE PHARMACIST DREW UP THE 0.85 ML (0.085 MG) FROM THE 1 MG/10 ML (1:10,000) ABBOJECT SYRINGE AS INDICATED BY THE BROSLOW TAPE. BECAUSE REMOVING THE DOSE FROM THE ABBOJECT WAS CUMBERSOME, THE PHARMACIST LOOKED AT THE BROSLOW TAPE AND MISTOOK THE ENDOTRACHEAL TUBE DOSE FOR THE IV DOSE AND GRABBED A MULTI DOSE VIAL OF EPINEPHRINE FROM THE CRASH CART AND DREW UP 0.85 ML (0.85 MG) FROM THE 1 MG/1ML (1:1,000) RESULTING IN AN OVERDOSE. IT WAS DEEMED THAT THE PATIENT ARRIVED TO THE HOSPITAL DECEASED AND THIS ERROR HAD NO BEARING ON THE OUTCOME OF THE PATIENT. THIS ERROR IS BEING REPORTED TO ISMP TO HOPEFULLY MAKE CHANGES TO THE BROSLOW TAPE TO PREVENT THIS FROM HAPPENING AT OTHER FACILITIES. THE EPINEPHRINE 1 MG/ML MDV VIALS WERE REMOVED FROM CRASH CARTS IN 2018 AND SOMEHOW MADE IT BACK INTO THE ED CRASH CARTS. THESE WERE ONCE AGAIN REMOVED FROM THE ED CRASH CARTS. DOUBLE CHECK OF PEDIATRIC DOSES IN A CODE SITUATION BY EITHER A PHARMACIST/NURSE OR NURSE/NURSE (WHEN THE PHARMACY IS CLOSED). REPORT TO ISMP IN HOPES TO UPDATE THE BROSLOW TAPE AND HELP PREVENT THIS FROM OCCURRING AT OTHER FACILITIES. TRAINING PHARMACIST ON HOW TO EFFECTIVELY REMOVE PEDIATRIC DOSES OF EPINEPHRINE FROM THE ABBOJECT SYRINGES.