Safety Policies and Procedures Manual

Emergency Epinephrine Auto- Injector Policy

SPPM 6.15

For more information contact:
   Compliance and Risk Management
   509-335-6893 / compliance.risk@wsu.edu

   Environmental Health and Safety
   509-335-3041 / ehsweb@wsu.edu

1.0  Overview and Purpose

WSU may make epinephrine auto-injectors available for the following purposes:

  • As part of its commitment to the safety and well-being of its students;
  • To provide a safe space for the consumption of food and beverages in its facilities; and
  • To safeguard health.

Epinephrine stands as the primary choice for addressing anaphylaxis, an intense and potentially life-endangering allergic response. Symptoms can affect several areas of the body, including breathing and blood circulation. An epinephrine auto-injector is an autoinjector or device that contains the medication epinephrine.

Washington law allows authorizes healthcare providers to prescribe epinephrine auto-injectors in the name of an authorized entity for use and in accordance with the law. (See RCW 70.54.440.) It also allows certain authorized health care providers (e.g., licensed pharmacists, advanced registered nurse practitioners, and physicians) to dispense epinephrine auto-injectors to an authorized entity. All WSU departments requesting or using an epinephrine autoinjector must ensure it is prescribed and dispensed from an authorized Washington licensed health care provider to WSU.

This policy (SPPM 6.15) establishes guidelines and requirements related to the maintenance, storage, and use of epinephrine auto-injectors by WSU departments in WSU facilities. This policy does not, however, require WSU departments to provide epinephrine auto-injectors.

1.1     Immunity from Liability

As an authorized entity under the law allowed to possess and make available epinephrine autoinjectors to WSU employees, agents, and other trained individuals, WSU is immune from liability in accordance with RCW 70.54.440(5), except in the case of gross negligence or willful or wanton misconduct, for:

  • Any injuries or related damages that result from the administration or self-administration of an epinephrine autoinjector,
  • Failure to administer an epinephrine autoinjector, or
  • Any other act or omission taken in accordance with RCW 70.54.440(5). 

WSU’s purpose of possessing and making available epinephrine autoinjectors is protect human life in a suspected severe allergic reaction or an anaphylaxis emergency while also availing itself of all immunities under the law that encourage the implementation of such activities. 

2.0  Applicability

This policy applies systemwide to all employees, except as follows.

This policy does not apply to:

  • Acquisition or use of epinephrine auto-injectors by licensed healthcare providers employed by or acting as agents of WSU; or
  • Self-administration of personally-prescribed epinephrine auto-injectors by individuals.

3.0  Definitions

Administer: The direct application of an epinephrine autoinjector to the body of an individual.

Authorized health care provider: An individual allowed by law to prescribe and administer prescription drugs in the course of professional practice. Under this policy, this is the Director of Medical Services at Cougar Health Services or an equivalent position at other WSU locations.

Epinephrine auto-injector: A single-use device used for the automatic injection of a premeasured dose of epinephrine into the human body. Epinephrine autoinjectors are available in various brand names such as Auvi-Q®, EpiPen®, and Symjepi®.

Self-administration: A person’s discretionary use of an epinephrine autoinjector.

4.0  Requirements and Procedures

4.1   Establishment of an Epinephrine Auto-Injector Program

The criteria for the establishment of an epinephrine auto-injector program by a WSU department include:

  • Operation of an activity, business, or event where allergens capable of causing anaphylaxis may be present, including a recreational or educational camp, food service operation, outdoor recreation, athletic facilities, or daycare facility.
  • For programs involving minors, WSU departments must review UPPM 50.32 for guidelines on reasonable accommodation and medication management.
  • Epinephrine auto injectors are available in two dosages based upon weight.  The 0.15 mg dosage is for individuals weighing 15 to 30 kg (33 to 66 pounds).  The 0.3 mg dosage is for individuals weighing greater than 30 kg (66 pounds).

    Departments must ensure the dosage(s) obtained are applicable to the appropriate weight(s) and the policy addresses a method to determine the appropriate dose.

  • Sufficient resources to ensure appropriate storage, maintenance, and inspection of prescribed epinephrine auto-injectors.
  • Sufficient resources to ensure identified employees receive adequate training, such as that identified in RCW 70.54.440(4) and WAC 246-570.
  • Designation of a department employee who has completed all required training and is responsible for general oversight of the department’s epinephrine autoinjector program, including compliance with WSU policies.
  • Establishment of post-incident reporting procedures that comply with applicable laws and regulations as required by RCW 70.54.440(6) and WAC 246-570-060.

4.2   Training

4.2.a    Department Responsibilities

Each department establishing an epinephrine auto-injector program must:

  • Identify and designate employees to participate in the program;
  • Cover the costs of its epinephrine autoinjectors; and
  • Ensure they complete all required training in accordance with this policy;

    All employees identified to store, maintain, provide, or administer epinephrine auto-injectors must undergo training as required by WAC 246-570 et. seq., and any required continuing education required by law;

  • Maintain a list of trained employees under this policy; and
  • Provide this list to the health care provider who is being requested to prescribe or dispense the epinephrine autoinjectors upon their request. 
4.2.b    Employee Responsibilities

Prior to participating in an epinephrine auto-injector program, an employee must complete education and training and furnish proof of completion of the training program to the department lead overseeing the program.

4.2.c    Training Program Requirements

The training program must be conducted by a nationally-recognized organization experienced in training laypersons in emergency health treatment or an individual approved by the Washington Department of Health (DOH). Training may be conducted online or in person and must cover the following:

  • Techniques on how to recognize symptoms of severe allergic reactions, including anaphylaxis;
  • Standards and procedures for the storage and administration of an epinephrine autoinjector;
  • Emergency follow-up procedures, including a requirement to call EMS immediately after an epinephrine auto-injector is administered.
  • Use and administration of an epinephrine autoinjector with adults and children; and
  • An assessment to ensure the participant gained appropriate competency in anaphylaxis and epinephrine autoinjector administration.

The WSU employee completing anaphylaxis training must receive a certificate of completion on a form developed or approved by the DOH, and provide a copy to Human Resource Services (HRS) and the WSU department lead authorized to oversee and manage this program.

Each approved department authorized to implement this program is responsible for paying all costs of training WSU employees for participation in this program.

4.3   Maintenance and Storage of Epinephrine Auto-Injectors

WSU departments are responsible for the proper maintenance and storage of epinephrine auto-injectors. Departments are to:

  • Store epinephrine auto-injectors in an area easily accessible to all employees authorized to administer an epinephrine auto-injector. The area must be communicated to all authorized WSU employees or agents, and clearly marked to ensure timely retrieval and administration of an auto-injector. The epinephrine auto-injectors must not be accessible to the general public or non-authorized employees.

    Important! Ensure the epinephrine autoinjector trainer (a needleless, non-drug containing device, included in the autoinjector carton) is (1) removed from the carton, or (2) not stored with the actual autoinjector that contains epinephrine.

  • Inspect epinephrine auto-injectors monthly and maintain a log of such inspections. The log should record the expiration dates of each epinephrine auto-injector. (See Section 6.0 for sample inspection log.)

    Departments must retain the log in accordance with University records retention requirements. (See the records series titled “Laboratory and Clinic Safety Program Records” in the All-University Records Retention Schedule – Safety Records table.)

  • Departments should begin the procurement of a new auto-injector immediately after the auto-injector is administered and 30-60 days prior to the expiration date of an autoinjector.
  • Regularly monitor for recalls using the U.S. Food and Drug Administration (FDA) Drug Recalls database. (See also Section 6.0: Appendix A.)
  • Ensure any expired or used epinephrine auto-injectors are disposed of appropriately (see SPPM 4.25) and replaced. Departments should contact the campus Environmental Health and Safety (EHS) for assistance in disposing of auto-injectors. (See Section 5.0.)
  • Otherwise store and maintain in a manner consistent with applicable laws and any requirements on the product packaging.
4.4     Post-incident Reporting Procedures and Follow-Up

All WSU departments must report incidents both internally and to the state as follows:

5.0     References and Resources

SPPM 2.24: Reporting Accidental Injuries and Work-Related Illnesses

Washington Department of Health (DOH) Epinephrine Autoinjectors website

Campus EHS for assistance:

  • WSU Everett Facilities and Emergency Management; telephone 425-315-4014; website WSUE Facilities Requests
  • WSU Pullman EHS; telephone 509-335-3041; e-mail ehsweb@wsu.edu
  • WSU Spokane EHS; telephone 509-335-9564; website WSUS EHS

    WSU Spokane EHS also provides information and assistance to WSU Health Sciences—Yakima (which includes College of Nursing—Yakima and College of Pharmacy and Pharmaceutical Sciences—Yakima).

6.0  Appendix A – Sample Inspection Log: Epinephrine Auto-injectors

Today’s
Date

Inspector Name and Initials

Lot
Number

Expiration Date

Additional Comments
(e.g., recalls)
         
         
         

_______________________
Revisions:  Oct. 2024 – new policy (Rev. 147)