1. Shastay, Ann MSN, RN, AOCN

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Distribute Instructions for Oral Dispenser

Take a look at the oral dispenser that accompanies morphine sulfate oral solution 100 mg/5 mL (Figure 1). The dispensing end of the plunger is pointed rather than flat-a specialty design not typically employed by key U.S. hospital suppliers of oral syringes (e.g., Baxter, Derrfield, IL; BD, Franklin Lakes; NJ, B. Braun, Bethlehem, PA). It accompanies some liquid products for the purpose of providing a low residual syringe volume after drug delivery. The pointy tip fits into the hub area, pushing out liquid and leaving little behind in the dead space. However, confusion has been reported regarding how to measure liquids-from the end of the pointed tip of the plunger, or from the widest part of the plunger above the pointed tip. Some nurses have been using the tip of the plunger to read the volume against the syringe scale, which is incorrect. All doses should be measured by aligning the widest part of the syringe plunger with the calibrated markings. By measuring from the tip, nurses will administer more than the intended dose. A pharmacist brought this issue to light when narcotic counts at three different facilities showed remaining volumes different than expected. Residents may have been given higher doses than prescribed if nurses measured the dose by aligning the plunger tip with the calibrated markings on the barrel. The error happened with a generic product, which is no longer on the market; however, Roxane distributes a morphine sulfate oral solution that uses the same syringe. The U.S. Food and Drug Administration-approved medication guide for the Roxane product has a section under "Patient Instructions for Use" that explains how to use the syringe, and has a detailed illustration showing how to accurately measure the product (Figure 2). Education of nurses, pharmacists, other healthcare professionals, and caregivers may be necessary if the "Patient Instructions for Use" information is not reaching them. Please review this information with patients and caregivers who use morphine 100 mg/5 mL or any other product packaged with this type of syringe. One company, Lannett, has a photo of the syringe and directions on how to use it on the sides of the carton.

Figure 1 - Click to enlarge in new windowFigure 1. Some nurses have used the end of the plunger tip to measure liquids.
Figure 2 - Click to enlarge in new windowFigure 2. Diagram and patient instructions from the newly approved Roxane medication guide detail how to properly measure a dose using the special oral dispenser.

Confusion Between EpiPen Training Device and Active Pen

We received a report about an emergency department's automated dispensing cabinet being stocked with an EpiPen (EPINEPHrine injection) training device instead of the active EPINEPHrine 0.3 mg autoinjectors used to treat anaphylaxis. This is not the first report we received about the confusion between the training device and the actual pen. The EpiPen 2-Pak, which contains two EpiPens and a training device (without a needle and the medication), is the only packaging available since Mylan (Canonsburg, PA) the manufacturer, discontinued distribution of individual EpiPens. The training pen is intended to help teach patients and family members how to properly use the pen to treat anaphylaxis. Although the training pen is visually different than the EpiPen, packaging both types of devices in the same box leads to confusion. We again contacted Mylan to emphasize the need to separate the packaging of active pens from training pens. We learned that they will continue to package the drug as is but are working on label improvements for the training pen to better indicate its intended use. Healthcare providers should be aware of the risk for confusion between the training pens and the actual pens. Home care nurses should make sure patients and caregivers know how to use the device by reviewing the procedure with the training pen. They should also make sure that the actual pens are stored separately from the training devices and are ready to use in an emergency.