We are submitting a case-based presentation illustrating medical errors in the use of epinephrine for the treatment of anaphylaxis. Readers will learn from mistakes made by other emergency caregivers in treating anaphylaxis. The article will specifically review the recommended use of epinephrine in the management of anaphylaxis. Four patients are presented who were seen in consultation by our outpatient allergy service. In all 4 cases, the history was suggestive of an episode of anaphylaxis in which emergency care providers mismanaged treatment. In 2 cases, the patients required ICU care after improperly receiving intravenous epinephrine. In the remaining 2 cases, epinephrine use was either omitted or significantly delayed in its administration. Our presentation includes a review of consensus statements regarding the treatment of anaphylaxis with particular regard to the use of epinephrine. We hope that this information will help prevent similar errors from harming other patients.