Check Twice, Jab Once: How to Make Sure You Are Administering the Correct Vaccine

Twice in the past few months, I have found myself at my local community pharmacy looking for an immunization; first for my bivalent COVID-19 booster and then for my annual influenza vaccine. As a fellow at the Institute of Safe Medication Practices (ISMP), one of my responsibilities is reviewing and coding error reports submitted through our medication error reporting portal. This makes me extra vigilant when I am on the other side of the health care spectrum, as a patient rather than a safety advocate. In both cases, I approached my vaccination appointment with my knowledge of common vaccine errors and the understanding that one of my roles as a patient is to help catch potential errors. 

In our September 22, 2022, Acute Care Medication Safety Alert, ISMP included both the featured article,  “ISMP National Vaccine Errors Reporting Program: 2020-2021 Analysis Focuses on Age-Related, Non-COVID-19 Vaccine Errors,” and safety briefs looking at the aforementioned COVID-19 vaccine labels and packaging concerns with the mpox (monkeypox) vaccine. 

The featured article took a break from COVID-19 and reviewed other types of vaccine errors reported through the ISMP National Vaccine Errors Reporting Program (ISMP VERP). More than two-thirds (68%) of the 1440 reported events were related to COVID-19 vaccines, and discussions on these errors and recommended safety strategies can be found in our June 30, 2022, featured article. 

Looking at the remaining non–COVID-19 related reports, we found nearly one-quarter (24%) of events involved patients receiving the wrong vaccine. To further narrow the scope, we focused on age-related vaccine events, and found a significant portion of these errors (44%) were attributed to lack of differentiation of age-related formulations of the same vaccine.

When looking at where these vaccine events occurred, only 3% were from inpatient settings, where safe medication use technologies like barcode scanning are more widespread and can help prevent these types of errors. Whenever possible, find ways to utilize barcoding in your setting to help avoid these errors. In addition to technological assistance, consider purchasing different age-specific formulations of the same vaccine from different manufacturers to better distinguish them, separating storage of pediatric and adult vaccines, and documenting the vaccine lot and expiration dates prior to vaccine administration, as this is often when health care workers detect an error.

For many more examples of vaccine errors, problematic packaging examples, troublesome vaccine abbreviations, and safe practice recommendations, see the full article.

Lastly, please continue to report vaccine-related errors internally and externally through the Vaccine Adverse Event Reporting System operated by the US Food and Drug Administration and Centers for Disease Control and Prevention. Additionally, to help us report errors and safety recommendations, continue reporting vaccine errors through the ISMP VERP.