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.

Help balance the load. Consider getting trained to administer vaccines, if you're not already...and encourage your tech colleagues to do the same. This can help free up your pharmacist's time.

Work as a team to utilize checklists, charts, etc...and don't rely on memory. If practical, offer to be the point person to update these tools promptly when changes occur.

Ensure proper storage and prep. Distinguish vaccines in the fridge or freezer with separate bins, different shelves, or eye-catching labels.

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 if you prep doses...and always have a pharmacist review. For example, the Moderna primary series or additional dose is 0.5 mL, but the booster is 0.25 mL.

As a best practice, label syringes as you draw them up...and keep doses separate. 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.

Streamline administration. Bring only the needed vaccines 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).

Respond to mix-ups appropriately. If an error occurs, notify your pharmacist ASAP...so they can determine next steps.

Follow your policy for reporting internally. Also help report administration errors and serious adverse events to VAERS (Vaccine Adverse Event Reporting System)...to alert colleagues nationwide.

Review our technician tutorial, The Basics of Immunization and Vaccines, to brush up your skills. And bookmark our COVID-19 Vaccines chart to compare authorized ages, doses, storage, etc.

Key References

  • https://www.ismp.org/resources/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines (11-19-21)
  • https://www.cdc.gov/vaccines/hcp/admin/downloads/vaccine-administration-preventing-errors.pdf (11-19-21)
  • https://www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-errors-deviations.pdf (11-19-21)
  • https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html (11-19-21)
Pharmacy Technician's Letter. December 2021, No. 371210



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