A patient recently died when a physician accidentally injected a 25-fold overdose of esmolol (Brevibloc). He administered the entire contents of a 10 ml ampule (2.5 grams) instead of a 10 ml (100 mg) vial for a loading dose. How did this happen?
The manufacturer had affixed a label, Amp must be diluted, to the ampule's neck, but this warning didn't prevent a communication breakdown. The nurse drew up the ampule's contents into a syringe and handed it to the physician, assuming that he'd further dilute it in an I.V. bag. Instead, he injected the syringe contents directly into the patient's I.V. line. The massive overdose caused an immediate cardiac arrest.
We're aware of at least 30 deaths or serious injuries associated with the ampule form of the drug. We've previously contacted the drug's manufacturer, Ohmeda, and the FDA about this problem, and the manufacturer is working to repackage the drug in a premixed form.
Copyright Springhouse Corporation Jun 1998
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