VACCINE ADMINISTRATION
Know your landmarks
As the drive to vaccinate the public against COVID-19 heated up, the Institute for Safe Medication Practices (ISMP) received reports of shoulder injury related to vaccine administration (SIRVA). A 68-year-old man who received his second COVID-19 vaccination with the Moderna product developed pain at the injection site and the back of the shoulder joint and was unable to raise his arm from the side of his body. He stated that the injection was given high on his upper arm, "hitting a nerve or injected into or too close to the shoulder bursa." He reported that the person giving the vaccine did not use any landmarks or fingerbreadths to locate the proper deltoid injection site.
Another patient, age 43, also suffered a vaccine injury when he received the injection high in the upper arm. Shoulder pain started in 4 to 5 hours, then worsened and impinged on movement. Pain and difficulty moving the arm persisted for weeks. An X-ray revealed a ligament tear and capsule involvement that might require surgical repair.
A third patient had severe left arm and shoulder pain beginning the afternoon following his early morning vaccination. The discomfort continued to worsen until it was excruciating. Again, the vaccine was administered high on the upper arm.
Many healthcare workers who do not normally administer vaccines are volunteering to assist with the national effort to vaccinate the public against COVID-19. Healthcare workers who administer any vaccine must understand and adhere to proper I.M. administration technique to prevent a potentially disabling SIRVA. Multiple resources related to proper vaccination technique are provided by the CDC and the Immunization Action Coalition. Compiled in articles by Deborah Wexler, MD, these resources can be found at http://www.ismp.org/ext/613 and http://www.ismp.org/ext/614. In addition, the University of Waterloo School of Pharmacy in Ontario, Canada, offers a helpful infographic on proper landmarking to prevent SIRVA that can be accessed at http://www.ismp.org/ext/611.
ORAL MORPHINE
Wrong syringe leads to wrong route error
An order for 2 mg of oral morphine was dispensed using a commercially available 15 mL bottle containing a 100 mg/5 mL (20 mg/mL) oral solution. An oral syringe that accompanies the 20 mg/mL morphine solution bottle has a mark for 5 mg as the lowest dose on the syringe scale (see photo). Because the 2 mg (0.1 mL) dose was not measurable using the provided syringe, a nurse prepared the dose using a 1 mL parenteral syringe. That allowed for the accidental connection of the parenteral syringe to the patient's venous access and the oral solution was administered I.V.
The practitioner who reported this event linked the error to not having a way to measure and administer doses under 5 mg using the accompanying oral syringe and asked ISMP to advocate for adding "smaller markings" on the syringe. However, morphine 20 mg/mL solution is intended only for opioid-tolerant patients who would be receiving higher doses in line with the markings on the accompanying syringe. For lower doses, an oral solution is available in a 2 mg/mL (10 mg/5 mL) concentration, which comes with a dosing cup. Thus, ISMP will not be advocating for changes to the morphine 20 mg/mL syringes. Although lack of a smaller dose marking on the syringe scale may have contributed to the nurse preparing the dose with a parenteral syringe, the way to minimize the risk of an error and patient harm is to use the most appropriate concentration of oral solution available. In addition, the pharmacy should dispense patient-specific, ready-to-administer doses in labeled oral or ENFit syringes, rather than dispensing a 15 mL bottle that contains 150 doses (2 mg each).
This error illustrates why syringes designed for parenteral medications should never be used to administer oral medications.