Alberta patients put at risk by adrenalin injection mistakes, documents show

A dozen patients in Alberta were incorrectly given intravenous shots of adrenalin over the past four years, mistakes that could have killed them, CBC News has learned.

A dozen cases found where epinephrine wrongly administered through IV

Lindsey Van Dyk went to an Edmonton-area hospital last June with typical allergy symptoms, and mistakenly got a shot of epinephrine through an IV. Within seconds she could hardly breathe. (CBC)

A dozen patients in Alberta were incorrectly given intravenous shots of adrenalin over the past four years, mistakes that could have killed them, CBC News has learned.

The details are outlined in leaked internal documents. In each case, the patient received a shot of adrenalin, or epinephrine (the hormone used in EpiPens), directly into the bloodstream, when it was supposed to be injected into muscle or under the skin.

The Institute for Safe Medication Practices Canada, an independent watchdog, says such mistakes — called "wrong route errors" — can cause "severe harm … or death."

Doctors generally prescribe epinephrine intravenously for life-threatening situations such as cardiac arrest. Because the effects are so immediate — a sharp rise in blood pressure, heart rate and heart contractions — it can save lives.

But epinephrine is also prescribed for allergic reactions, and that's where the confusion arises.

Health workers accustomed to giving epinephrine through an IV in life-threatening cases sometimes administer it that way when an IV is not required: the right medication, given the wrong way.

Typically, when a patient has an allergic reaction, epinephrine should instead be given as it is with an EpiPen — through muscle or under the skin, where it is more slowly absorbed.

Potentially deadly

"If I wouldn't have been in the shape I had been in, if I would have been a little overweight, I wouldn't have made it out that day," said Lindsey Van Dyk, one of the dozen patients in Alberta who were incorrectly treated.

Van Dyk, 32, said her doctor told her the error could have killed her.

She walked into an Edmonton-area hospital in June with what she describes as typical allergy symptoms: hives on her stomach and a slightly swollen throat.

The allergic reaction was likely brought on by an anti-inflammatory ingredient in the mosquito-bite lotion she put on her daughter that morning, she said.

It's a common allergic reaction she has dealt with for years. She expected routine treatment and an hour, at most, in hospital.

But she started to worry when the nurse said she would give her epinephrine and prepared her arm for an IV.

"Is this a new way of giving it?" Van Dyk said she asked the nurse at the time. She was used to getting epinephrine injections, but had never had one like this. The drug had only ever been given to her as a shot to her thigh or stomach, as with an EpiPen.

Three seconds after the drug passed through the IV into her vein, Van Dyk could hardly breathe.

"My vision started going and my chest hurt and I couldn't move," she said.

"I ended up throwing up all over everybody in the room. The doctor immediately walked in and asked what they gave me … I could tell by her face that something was wrong."

High numbers, high risk

"You could cause death, potentially," said David U, president and CEO of the Institute for Safe Medication Practices Canada.

He was "not surprised" to hear Alberta has seen at least a dozen "wrong route" mistakes since 2011. His group issued a countrywide safety bulletin last year about the danger, after it learned of two such errors in Canada.

There are no reports that anyone in Alberta has died because of this mistake. But U believes such cases are vastly underreported, since most provinces — including Alberta — use a voluntary error reporting system.

"It's a very common issue, because of the increase in food allergies and the use of chemotherapy and other agents that can cause an allergic reaction," he said.

U said the easiest solution would be to stock hospitals with EpiPens — which are already associated with allergy treatment and cannot be administered intravenously. But at roughly $100 per needle, that solution is often considered cost-prohibitive.

Haunting mistakes

"That's horrible," said Van Dyk. "What's more expensive really: having a $150 kit sitting in a hospital or having somebody lose their lives, who has children? Or a newlywed? It's a tragedy, to think about it."

After what she calls her "heart event," Van Dyk had to check in to the Misericordia Hospital for more observation and treatment. She sees a cardiologist regularly and has been told there is no lasting damage to her heart.

But the single mother missed two weeks of work, and she has had regular panic attacks and nightmares ever since.

"When you go from playing baseball and working construction to not being able to get off the couch without breathing hard, breathing heavy — it's really hard," she said, describing how it felt in the weeks immediately afterward.

The shock still haunts her.

"I thought, 'Oh my God. Just go in for this little thing and then my child could have had no mom?'" she said.

Apologies and plans

She has asked Alberta Health Services (AHS), the provincial health authority, for compensation. Van Dyk wants one year's salary (about $100,000) as compensation.

Almost one year later, she has received no official word on whether she'll get it.

AHS said it cannot comment on specific patient conditions or cases "to protect patient privacy and confidentiality."

"We sincerely regret this event and offer our deepest apologies to the patient," a spokesperson wrote in an email. "The incident was reviewed with all parties involved and additional training was provided for involved staff."

That statement goes on to say AHS is working on a provincial prevention strategy that would include options like increased training and adding EpiPens or special epinephrine kits to hospitals.


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