Human Error and Adverse Hemodynamic Events With Prediluted Push Dose Norepinephrine in the Emergency Department

Critically ill emergency department (ED) patients often experience severe hypotension requiring immediate intervention with “push dose vasopressors” (PDPs) to provide temporary hemodynamic (HD) support. Bedside preparation and dilution of PDPs is prone to both mixing errors and adverse events. Recognizing this risk, we implemented pre-diluted norepinephrine (NE) syringes in the ED critical care area. This study aims to assess the occurrence of human error and adverse events with push dose NE in the ED.

This was a prospective cohort study of adult patients receiving push dose NE in an urban ED from June 11, 2025, to December 11, 2025. We implemented pre-diluted NE 4 mcg/mL intravenous (IV) syringes (10 mL) in the ED critical care area, removed pre-diluted phenylephrine, and disallowed bedside dilution of epinephrine as well as utilization of undiluted IV epinephrine outside of cardiac arrest. For each push dose NE administration, trained staff monitored HD parameters over the following 10 minutes and queried clinicians and pharmacists regarding human error (i.e., incorrect drug or dose). Adverse HD events were defined as new heart rate (HR) > 140 or < 60 bpm, systolic blood pressure (SBP) > 180 mmHg, and ventricular dysrhythmia (VD). The primary outcome was incidence of human error and adverse HD events associated with push dose NE.

There were 70 push dose NE administrations in 50 unique patients. Of those who received NE, 17 received a second dose, and 3 received a third. The median dose was 14 mcg (IQR 8-20), with the most common dose being 12 mcg. Nurses administered all doses aside from one by the pharmacist. The most common indications for push dose NE were peri-intubation hypotension followed by cardiogenic shock, hemorrhagic shock, and sepsis. From baseline to 2 minutes post dose, the median change in SBP was 6 mmHg (IQR -4.75-23.75) and HR was 0 bpm (IQR -4.75-4.75). Adverse HD events following NE included 9 new HR > 140 bpm (12.9%), 13 new HR < 60 bpm (18.6%), 8 episodes of SBP > 180 mmHg (11.4%), and 0 VD. No human error related to incorrect drug or dose were reported.

Implementation of pre-diluted push dose NE was associated with no human error or VD. New tachycardia and hypertension occurred but did so at rates similar or lower than other PDPs used in the ED. Future study directions will involve collecting a larger sample size to further characterize the safety and efficacy of push dose NE in the ED.