Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP) received the following reports of injection and wrong-route errors that will likely happen again unless risk reduction strategies are implemented.
SIRVA persists
The ISMP Vaccine Errors Reporting Program (www.ismp.org/report-medication-error) continues to receive reports of shoulder injury related to vaccine administration (SIRVA).
A 68-year-old man who received his second dose of the Moderna COVID-19 vaccine 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, a 43-year-old man, also suffered a vaccine injury when he received the injection high in the upper arm. Shoulder pain started after 4 to 5 hours and then worsened, with an impingement in movement. Pain and difficulty moving the arm persisted after 3 weeks and he contacted an orthopedist. His X-ray revealed a ligament tear and capsule involvement with the possibility of requiring surgical repair.
A third patient who received his second dose of the Pfizer–BioNTech COVID-19 vaccine had severe left arm and shoulder pain beginning the afternoon following his early morning vaccination. The discomfort worsened and became excruciating. Again, the vaccine had been administered high on the upper arm.
It is critical for health care workers who administer the vaccine to understand proper I.M. administration technique to avoid a preventable and disabling SIRVA. The Immunization Action Coalition (www.immunize.org/technically-speaking/20181023.asp) has compiled several excellent resources on proper injection technique.
Use the right syringe
A wrong-route error happened in a hospital after 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 100 mg/5 mL morphine solution bottle has a mark for 5 mg as the lowest dose on the syringe scale.
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, which allowed for the accidental connection of the parenteral syringe to the patient’s I.V. line, and unfortunately, the oral solution was administered
intravenously.
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. However, morphine 100 mg/5 mL solution is intended only for opioid-tolerant patients who would be receiving doses in line with the syringe markings. For lower doses, a 10 mg/5 mL (2 mg/mL) oral solution that comes with a dosing cup is available and should be used.
To minimize the risk of an error and patient harm, it’s important to use the most appropriate concentration of morphine oral solution available. Furthermore, hospital pharmacies 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).
Barcode scanning could verify the drug and concentration, particularly if both concentrations are available.