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A 7-year-old goes in for routine ear surgery and dies after receiving a dose of concentrated epinephrine. Surely this is an isolated case — or is it? A recent survey of safety errors in otorhinolaryngology practice shows that of 466 responses, there were five cases of inadvertent injection or placement of 1:1,000 epinephrine.

Survey draws attention to outpatient surgery errors: Is your program at risk?