ISMP issues safety brief about EpiPen 2-Paks

The new EpiPen 2-Paks may cause confusion among hospital staff, according to a new safety brief from the Institute for Safe Medication Practices (ISMP).

ISMP said two hospitals recently switched to stocking epinephrine 0.3 mg auto-injectors in their automated dispensing cabinets (ADCs) instead of 1 mg ampuls, to decrease the risk of administering the full 1 mg dose in the ampul instead of the 0.3 mg dose needed to treat anaphylaxis.

“That worked fine until distribution of individual EpiPens was halted by the company [Mylan Specialty]. Now only an EpiPen 2-Pak is available,” according to the ISMP safety brief. The 2-Pak holds two EpiPens plus a training pen, meant for training patients and their family members. In one hospital, a training pen was being stored in the emergency department’s ADC.

“The training pens and the actual pens do look very similar, with the instructions included on the pen and the slight difference in the color of pen for difference doses. To a trained eye and a not-so-busy healthcare provider, this is easily detectable,” said P. Tim Rocafort, PharmD, assistant professor at the University of Maryland School of Pharmacy in Baltimore. “However, in an emergency situation with personnel that may not be fully trained and in the right mindset, these safety points may be easily omitted and mistakenly thought for another, endangering the patient’s life.”

To help alleviate potential errors, pharmacists can create labels that distinguish the different pens, prior to storing them in the ADC, Rocafort suggested. Training pens should be stored in a different storage area and should be clearly labeled, “FOR TRAINING PURPOSES ONLY,” he added.

Mylan Specialty will continue to package the EpiPens as they are, but the company is working on label improvements for the training pen, according to ISMP.