September 30, 2011: Collaborative Failure Mode and Effects Analysis (FMEA) - Reducing the Risk of Inadvertent Injection of Concentrated Epinephrine Intended for Topical Use
Given the high risk of harm or death associated with the inadvertent injection of epinephrine 1 mg/mL, further study of the management of this medication was deemed necessary. An Ontario hospital volunteered to assist ISMP Canada with a prospective analysis of processes related to the use of concentrated epinephrine intended for topical use in the operating room. The hospital had already implemented enhancements to its operating room processes to reduce the potential for error and welcomed the opportunity for ISMP Canada to assess these enhancements and to share learning with others upon completion of the FMEA.ISMP Canada gratefully acknowledges the Ontario hospital and team members who participated in this analysis, as well as the Ontario Ministry of Health and Long-Term Care, which provided funding support for the FMEA project.
Canadian facilities that would like to receive a copy of the final report should send a request by email to info@ismpcanada.org, or call 416-733-3131 or toll-free at 1-866-544-7672.
