Ephedrine and epinephrine aren’t just easy to confuse because they have similar names. The drugs also are often stored next to each other and come in the same doses.
To reduce the chance of mix-ups, the Institute for Safe Medication Practices (ISMP) recommends that providers:
- Don’t store epinephrine and ephedrine side-by-side.
- Use tall man letters to highlight differences between the names. ISMP recommends using ePHEDrine and EPINEPHrine.
- Use screen alerts on automated dispensing cabinets.
- Use pre-filled epinephrine syringes.
- Keep large vials of epinephrine out of clinical areas.
- Have the pharmacy prepare infusions and bolus doses for these drugs, except in emergencies.
A key to avoiding any drug mix-up is to have the person receiving a verbal order read it back to the prescriber. The person receiving the order should write it in a chart or on a prescription and read it back from the chart or prescription, not from memory.