Medication Errors with Inhalant Epinephrine Mimicking an Epidemic of Neonatal Sepsis

MEDICATION errors in the care of hospitalized patients are reported to occur as often as 1 in every 20 to 1 in every 6 doses of medication administered. 1 2 3 4 In January 1982, we investigated an outbreak of severe, unexplained illness occurring on a neonatal ward at one hospital. Patients were initially diagnosed as having neonatal sepsis, but epidemiologic and laboratory investigation showed that these illnesses were the result of a recurring medication error involving the substitution of epinephrine for vitamin E. Description of the Outbreak On January 18 and 19, 1982, five babies on the neonatal intermediate-care ward at one hospital . . .