Implement Guardrails to Prevent COVID-19 Vaccine Errors

You play a critical role in preventing COVID-19 vaccine errors.

Ensure proper storage. Cold-chain errors have led to hundreds of wasted doses. Verify storage requirements in the most recent emergency use authorizations (EUAs) before putting vaccine stock away.

Use designated containers or shelves in the fridge or freezer...or even separate storage units...to help staff grab the right vaccine.

Be vigilant with prep. Mix-ups include giving diluent only...incorrectly diluted vaccine...or a whole vaccine vial instead of one dose.

Ensure that only Pfizer-BioNTech vials are diluted...and draw up 1.8 mL of the preservative-free normal saline diluent. For example, if you get 2 or 10 mL diluent vials in your kits, discard the excess.

Don't shake the vials. Gently invert Pfizer-BioNTech before and after diluting...and swirl Janssen or Moderna before drawing up each dose.

Double-check that you've drawn up 0.3 mL doses with the Pfizer-BioNTech vaccine...or 0.5 mL with Janssen or Moderna. If staffing permits, get an extra set of eyes to verify.

Have a plan to prevent waste. For example, draw up doses in small batches for confirmed appointments...use prefilled syringes with the earliest discard time first...and keep a waiting list for no-shows.

Limit administration issues. Errors include accidentally giving extra doses...subcutaneous instead of IM administration...vaccine leaking out of syringes...and patients pulling away during the injection.

Review the immunization card or your state's registry...to avoid unnecessary doses and ensure you give the same product for second doses.

If you estimate a patient got less than half the dose due to leakage, give a new full dose at the same visit in the opposite arm. But don't repeat the dose if you're sure the patient got more than half.

Use our chart, COVID-19 Vaccines, as a quick comparison guide...and for updates on beyond-use dates, authorized ages, and dosing.

Key References

  • www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-errors-deviations.pdf (4-23-21)
  • www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-quick-reference-guide-2pages.pdf (4-23-21)
  • https://ismp.org/resources/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease-2019-covid-19 (4-23-21)
  • www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i2-COVID19-Vaccine-Error-Prevention.pdf (4-23-21)
  • www.usp.org/covid-19/vaccine-handling-toolkit (4-23-21)
Pharmacist's Letter. May 2021, No. 370502



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