Work with nursing and support staff to organize and delegate tasks.
For example, have a plan for prepping supplies and paperwork, drawing up doses, and administering immunizations.
Ensure your team relies on checklists, charts, etc...not memory. Date these materials...and have a point person keep them current.
To limit product and dosing mix-ups, consider giving certain vaccine brands on specific days, such as “Moderna on Monday.”
Also separate vaccines using labeled containers or shelves...or even different fridges or freezers.
Avoid using cap color alone to differentiate unused vials. Reinforce reading labels closely...and consider adding colored stickers.
For example, Pfizer-BioNTech COVID-19 vials for age 12 and up have gray caps and labels for the primary series AND bivalent booster.
And the Moderna bivalent booster has a dark blue cap...just like monovalent Moderna vials for 6 months to 5 years and 6 to 11 years.
Plus vials of Moderna’s primary series for kids 6 to 11 may say “booster doses only”...since they used to be monovalent adult boosters. Mark these “kids 6 to 11” until products with correct labels arrive.
Have the team follow a standard process when drawing up doses...and recommend getting a second set of eyes whenever possible.
Encourage labeling syringes as each dose is drawn up...and taking vaccines to the administration area for 1 patient at a time.
Continue to ask open-ended questions to confirm the right patient (name, birth date, etc)...and right vaccine (product, dose, etc).
Also ask the patient to read the syringe label if practical.
Follow your policy for internal reporting if an error occurs...and also report to VAERS (Vaccine Adverse Event Reporting System).
Use our resource, Vaccine Administration Strategies, for ways to limit risk of injury, injection pain, and patient anxiety.
- https://www.ismp.org/alerts/age-related-covid-19-vaccine-mix-ups (9-23-22)
- https://www.ismp.org/alerts/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines (9-23-22)
- https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us-appendix.html#appendix-d (9-23-22)
- https://www.cdc.gov/vaccines/hcp/admin/downloads/vaccine-administration-preventing-errors.pdf (9-23-22)