Fatal outcome after inadvertent injection of epinephrine intended for topical use.

Four years ago, the ISMP Canada Safety Bulletin highlighted a substitution error involving inadvertent injection of epinephrine 1 mg/mL (epinephrine 1:1,000) intended for topical application during an elective, outpatient ENT (ear, nose, throat) procedure. Recently, a similar incident with different underlying circumstances led to the death of a patient. The reporting hospital for the more recent incident has since implemented enhancements to its medication-use system. This bulletin was developed collaboratively as a call to action.