From ISMP: Drug Name Confusion: Ephedrine and Epinephrine
The Institute for Safe Medication Practices is warning again about the possibility of mix-ups between ephedrine and epinephrine. Not only do the names of these drugs look and sound similar, but since they're both used as vasopressors and vasoconstrictors, they are often stored next to each other. Also, both drugs may be packaged in 1mL ampules or vials.
ISMP cites a recent case in which a 57-year-old patient was admitted for excision of a neuroma on her foot. She became hypotensive and nauseated soon after an IV was started preoperatively. An anesthesiologist gave a verbal order for ephedrine, but the nurse taking the order heard epinephrine, and that's what the patient was mistakenly given.
