Work as a Team to Prevent Vaccine Errors

You'll need to stay alert for errors with COVID-19 vaccines...due to boosters, pediatric doses, catch-up with other vaccines, etc.

Planning. Increased demand can be a recipe for mix-ups. Try to balance the load. For example, federal guidance authorizes qualified techs and interns to administer COVID-19 and flu vaccines.

Train your team to rely on checklists, charts, etc...not memory. Have a point person update these tools promptly when changes occur.

Keep vaccine supplies ready to go in baskets or kits...and consider using certain colors for different vaccines.

Storage and prep. Distinguish vaccines in the fridge or freezer with separate bins, different shelves, eye-catching labels, etc. For instance, store pediatric vaccines separately from adults.

Use cap color as a clue to differentiate unused vials. But ALSO check the vial label...to limit mix-ups once caps are removed.

Follow a standard process...and ask for a second set of eyes if you can. For example, triple-check that you've drawn up 0.5 mL for the Moderna primary series and additional dose...or 0.25 mL for the booster.

As a best practice, label syringes as you draw up doses. Consider using preprinted labels to improve efficiency.

Avoid going over the max of 20 punctures currently authorized for each Moderna vial. For instance, note each full dose with a "" and boosters with an "X"...to track punctures and calculate waste.

Also be aware, the ORANGE-capped Pfizer-BioNTech vials for kids 5 to 11 are labeled with the manufacture date...NOT an expiration date.

Administration. Take only the vaccines you need to the administration area...for one patient at a time. Recent errors include patients getting the wrong vaccine, such as COVID-19 instead of flu.

Ask open-ended questions to confirm you have the right patient (name, birth date, etc)...and the right vaccine (product, dose, etc). If practical, ask the patient to read the syringe label as another check.

If an error occurs, follow your policy for reporting internally. Also report administration errors and serious adverse events to VAERS (Vaccine Adverse Event Reporting System).

Bookmark our chart, COVID-19 Vaccines, as a reference to compare authorized ages, doses, storage, etc.

Key References

  • https://www.ismp.org/resources/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines (11-18-21)
  • https://www.cdc.gov/vaccines/hcp/admin/downloads/vaccine-administration-preventing-errors.pdf (11-18-21)
  • https://www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-errors-deviations.pdf (11-18-21)
  • https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html (11-18-21)
Pharmacist's Letter. December 2021, No. 371205



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