Study objective: To evaluate the use of ipecac by health care professi
onals. Design: A descriptive case series based on a one-year review of
all calls to a poison center. Setting: A university hospital-affiliat
ed regional poison center. Interventions: The use of ipecac was judged
appropriate or inappropriate based on the consensus of three professi
onals associated with the poison center using predetermined contraindi
cations. Measurements and main results: In 20% of cases in which ipeca
c was used, its use was inappropriate. The most common inappropriate s
ituation was that too much time had elapsed from the time of ingestion
. Among adults the most common contraindication was the ingestion of a
substance known to cause altered mental status. Among children, the m
ost common contraindication was the ingestion of a nontoxic substance
or amount of substance. The poison center recommended ipecac inappropr
iately less often than emergency departments and usually in children i
ngesting a nontoxic substance. EDs recommended ipecac inappropriately
with a broader range of contraindications and more often in adults. Co
nclusion: Ipecac has potentially adverse consequences and should not b
e used reflexively. Providers of emergency care should be educated abo
ut possible contraindications to its use.