Article: Patient safety first alert--epinephrine and phenylephrine in surgical settings.

Epinephrine and phenylephrine previously have been identified as high-alert medications, a designation that results from the narrow margin of safety associated with their use. (1) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), AORN, the United States Pharmacopeia (USP), and the Institute for Safe Medication Practices all have received reports of adverse events involving epinephrine and phenylephrine in the OR and other surgical settings. These adverse events most frequently were related to solutions being diluted incorrectly or the wrong concentration being used.

A case involving mislabeled epinephrine 1:1,000 that resulted in the ...

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