Vaccine Errors — Prevention Strategies

Look-alike products, sound-alike names, limited storage space, unclear product labeling, differing preparation instructions, staffing shortages — these are all risk factors for vaccine errors. In the month following introduction of a pediatric COVID-19 vaccine, the Institute for Safe Medication Practices (ISMP) received error reports involving hundreds of children. (To provide perspective, over 4 million children received the vaccine during the same time period.) 

 

Although many of the recommendations below were published for COVID vaccine errors, the strategies can be applied to reduce errors related to many other vaccines as well.

 

            • Segregate and store vaccines in refrigerators or freezers that are organized and clearly labeled. Assign adequate space for bins/containers to lay flat and upright so labels are easy to read. Consider bins with lids for additional safety.

 

• Store adult and pediatric vaccines apart from one another, in separate bins and clearly labeled. Emphasize "adult" or "pediatric," or specify the age group on the label. Pictographs may also be added.

 

• Label all individual syringes containing vaccines. Strips of pre-printed labels may help facilitate this.

 

            • Use barcode scanning verification wherever it is available in your medication management system.

 

• Provide a separate area for vaccine administration, away from interruptions and distractions.

 

• Bring only the intended (and labeled!) vaccine syringe(s) for one patient into the vaccination area.

 

            • Ask the parent or patient for at least two patient identifiers, such as full name and date of birth, immediately prior to vaccination. For pediatric patients, verify the age and the name of the vaccine they have requested.

 

• If possible, schedule specific vaccine clinics during dedicated blocks of time each day (for example, separate flu clinic times from COVID times). Ensure adequate staffing is available for vaccine administration.

 

• Provide education and resources to your nursing and provider colleagues on safe medication practices. Don't assume they are familiar with dosage and preparation instructions for newer vaccines. Safe storage and labeling practices may not be second nature to them and their staff. 

 

• Report all vaccine errors internally and externally. This allows for shared learning across the country, resulting in better understanding and recommendations for error avoidance/reduction. External programs include the US Food and Drug Administration (FDA) Vaccine Adverse Event Reporting System (VAERS, https://vaers.hhs.gov/) and ISMP's National Vaccine Errors reporting Program (ISMP VERP, https://www.ismp.org/report-medication-error).