Improving Patient Safety by Changing Labels

While epinephrine has been in the news lately because of the skyrocketing costs of the EpiPen®, a lesser known problem with the administration of this life-saving medication is ratio expressions. Many life-saving resuscitation drugs, including lidocaine, epinephrine, and sodium bicarbonate, are expressed in ratio concentrations (1:1,000 or 1:10,000), and in emergency situations, this labeling can cause inadvertent mistakes. In order to improve patient safety, here are some suggestions.

If undiluted epinephrine is administered via IV, it can produce a dramatic and life-threatening event. It is better if the label on single entity medications shows mg/mL dosages. So, for example, undiluted epinephrine would be labeled 1 mg/1mL. The diluted concentration is labeled 0.1 mg/1 mL. In an emergency situation, all those zeros (1,000 vs. 10,0000) get confusing.

In addition, confusion about similar drug names jeopardizes patient safety. Epinephrine and ephedrine have similar packaging and can be stored near one another in medicine carts and storage areas. They both start with the same letters, and they are both vasopressors, as well. These medications are not used interchangeably; ephedrine has a much lower potency.

Safe Practice Strategies

  • Don’t assume healthcare workers know ratio expressions of concentrations or know how to calculate dosages accurately
  • Use prefilled syringes when possible
  • Store a single concentration only
  • Use warning labels to minimize confusion where you cannot store a single concentration of a drug
  • Do not store epinephrine and ephedrine side-by-side
  • Post a dose conversion chart on emergency carts; make review of these charts regular and ongoing, for example at annual CPR trainings

In order to teach proper administration, simulated meds should have labels that directly mimic drug labels found in clinical settings. Students should know all the ways drugs can be administered and proper dosages. Pocket Nurse offers Demo Dose®, its proprietary line of simulated medications, in order to teach proper medication management. Demo Dose does not use ratio expressions on its labeling, in order to comply with patient safety concerns. Learn more.

1. From PA PSRS, “Let’s Stop this ‘Epi’demic!—Preventing Errors with Epinephrine”

2. From ISMP, “It Doesn’t Pay to Play the Percentages”

3. From ISMP Canada, “Risk of Mix-ups between Ephedrine and Epinephrine” [PDF]

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