This document summarizes a case report about a medication error involving epinephrine administration. A 40-year-old female patient experiencing anaphylaxis was incorrectly given an intravenous dose of 0.5 mg epinephrine instead of intramuscularly. This resulted in a myocardial infarction due to epinephrine overdose. The standard treatment for anaphylaxis is 0.3-0.5 mg of epinephrine intramuscularly. Intravenous administration should only be used if intramuscular doses are not effective and the patient is monitored. Route of administration is important as it determines onset and effects. This case highlights the risks of intravenous epinephrine administration and improper dosing.

1. SCHOOL OF PHARMACY
Subject: PRINCIPLES ON MEDICAL PHARMACOLOGY
Subject code: SPH1102
Assignment #1: Case Report
EPINEPHRINE OVERDOSE DUE TO INCORRECT
ROUTE OF ADMINISTRATION
Prepared by : ANNISA HAYATUNNUFUS (ID: 012014052438)
Lecturer’s Name : Dr. ERWIN MARTINEZ FALLER
Date of submission : March 23rd, 2015

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I. INTRODUCTION
A case study indicated a medication error of a 40-year-old female patient with
an allergy anaphylaxis. This is shown by laryngeal edema and hypotension(1)
following ingestion of seafood. Patient was given a 0.5 mg (1:1000) dose of
epinephrine intravenously rather than intramuscularly which resulted in ST
elevation and myocardial infarction.
While epinephrine is the recommended first line treatment for patients with
anaphylaxis,(4) the standard adult dose is 0.3 – 0.5 mg(7) with the concentration
ratio of 1:1000 as IM or 1:10000 as IV.(2)
Route of administration plays an important role in providing a medication to a
patient as it affects the onset of action and therapeutic response.(8) An error in the
route of administration may not only resulted in the loss of therapeutic effect, but
also worsen the patient’s condition.
After the complication, the patient was given 2 doses of 0.4 mg sublingual
nitroglycerin. Her condition went back to normal afterwards.
II. DISCUSSIONS
One of the most adverse events regarding the administration of epinephrine is
when it is given in overdose or intravenously, especially for elderly patients and
patients with hypertension, arteriopathies, or known ischemic heart disease.
Complications to this error has been associated with the induction of fatal cardiac
arrhythmias and myocardial infarction.(4)
In this particular case of study, the concentration of epinephrine was not dilute
enough to be administered intravenously. Thus, the medication was followed by a
myocardial infarction as a result to epinephrine overdose. Worse condition such as

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Figure 1. Algorithm for the treatment of anaphylaxis (UK
Resuscitation Council)
cerebral haemorrhage can also be resulted by a high-dose or accidental IV
injection of epinephrine in elderly patients.(10)
It must be noted that intravenous epinephrine should only be given if the
patient does not respond to repeated intramuscular epinephrine and is under
adequate cardiovascular monitoring.(3, 4)
Health practitioner must
also remember not to mistake a
1:10000 concentration of IV
epinephrine with the usual
1:1000 IM epinephrine. A
concentrated dose must be
diluted first in order to achieve
the correct strength.(8)
The Pennsylvania
Patient Safety Reporting
System (PA-PSRS) has
received numerous reports of
accidental administration of
concentrated epinephrine.(2)
One of the cases reported
stated as follows, “Tragically, a 16-year-old boy was brought into the emergency
department with priapism and died due to an epinephrine overdose. A urologist
ordered epinephrine, but he thought that the 1:1,000 ratio on the epinephrine 1
mg/mL label meant that the epinephrine had already been “prediluted” with 1,000
mL of fluid. The patient received 4 mL of 1:1,000 undiluted epinephrine injected

4. 4
into his penis. The patient arrested and died when the epinephrine reached his
systemic circulation.”(2)
An error like such highlights the problem in drug concentration presentation.
Only a few drugs have concentrations expressed as a ratio or percentage. These
expressions are error-prone because practitioners may not recognize the difference
between dose concentrations. It is also hard to distinguish a concentration when
there is too much zeros written (i.e., 1,000 looks like 10,000).(2)
As a health practitioner ourselves, we should consider some few things in
order to minimize this kind of error. First, we should not expect all health
practitioners to be proficient at calculating doses of drugs nor be familiar with
various expressions of concentrations. In such case, posting a dose conversion
chart can help practitioners become more aware of how to do the dosing. We
should also keep in mind to store a single concentration and label it clearly to
avoid confusion between two different concentrations. Moreover, to ensure an
independent double-check system, it would be best to have pharmacy prepare all
infusions when possible.(2) Last but not least, it is important to keep a constant
monitor on the condition of patient even after drug administration as it is
dangerous if the patient is left unsupervised for even a short period.(9)
III. CONCLUSION
We have reported a case of a myocardial infarction that occurred after the
administration of IV epinephrine for moderate anaphylaxis. The complication is
due to the wrong route of administration which leads to the administration of
undiluted IV epinephrine. Patient should have been administered epinephrine
intramuscularly in the first place, rather than intravenously. Ultimately, the patient
recovered after being given 2 doses of nitroglycerin.(6)

5. 5
IV. REFERENCES
1. American Heart Association. (2005). 2005 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care, Part 10.6: Anaphylaxis. Circulation, an American Heart Association
Journals.
2. ECRI Institute & ISMP. (2006, September 3). Let's Stop This "Epi" demic!—
Preventing Errors with Epinephrine. Retrieved from Pennsylvania Patient
Safety Authority:
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3
)/Pages/16.aspx
3. Lieberman, P. (2012, March 6). Epinephrine in the Treatment of Anaphylaxis.
Retrieved from American Academy of Allergy Asthma & Immunology:
http://www.aaaai.org/ask-the-expert/epinephrine-in-anaphylaxis.aspx
4. McLean-Tooke, A., Bethune, C. A., Fay, A. C., & Spickett, G. P. (2003).
Adrenaline in the Treatment of Anaphylaxis: What is the Evidence? British
Medical Journal.
5. Reardon, P. M., & Magee, K. (2013). Epinephrine in Out-of-Hospital Cardiac
Arrest: A Critical Review. World Journal of Emergency Medicine. Retrieved
from World Jounal of Emergency Medicine.
6. Shaver, K. J., Adams, C., & Weiss, S. J. (2006). Acute Myocardial Infarction
after Administration of Low-Dose Intravenous Epinephrine for Anaphylaxis.
Canadian Journal of Emergency Medicine.

6. 6
7. Toy, E., Loose, D., Tischkau, S. A., & Pillai, A. S. (2014). Case Files
Pharmacology, 3rd Ed. McGraw-Hill Education.
8. Drugs.com. (n.d.). Epinephrine Dosage. Retrieved from Drugs.com:
http://www.drugs.com/dosage/epinephrine.html
9. Pain Community Center. (n.d.). Route of Administration. Retrieved from Pain
Community Center: http://www.paincommunitycentre.org/article/route-
administration-0
10. iPhone Application: MIMS Indonesia. (Version 1.2.0.1.). Special Precautions.
Epinephrine (Phinev).