How to combat the Top 10 vaccine errors

March 31, 2015

The Institute for Safe Medication Practices has identified factors contributing to the top 10 vaccine-related errors and released a report with recommendations to combat these errors.

The Institute for Safe Medication Practices (ISMP) has identified factors contributing to the top 10 vaccine-related errors and released a report with recommendations to combat these errors.

Six-week vaccination course offered

ISMP worked with the California Department of Public Health three years ago to develop a national vaccine-error reporting system. Data collected by the ISMP National Vaccine Errors Reporting Program (VERP) is sent to the FDA and Centers for Disease Control and Prevention’s (CDC) Vaccine Adverse Event Reporting System (VAERS) to assess side effects from vaccines.

Approximately 1,000 reports submitted to VERP were analyzed to find out the vaccines involved in errors and the common factors that contribute to vaccine errors. ISMP published this data in December last year.

In ISMP’s recent report, various recommendations are offered to help lower the risk of 10 vaccine-related errors.

1)Age-specific formulation errors. The patient’s age should be verified before prescribing, dispensing, or administering a vaccine.  ISMP suggests that the healthcare professional ask the patient’s date of birth and refer to the patient’s health record or immunization record. It is also important to check the immunization schedule and Vaccine Information Statement from the CDC.

Also, add warning labels to vaccines delivered to the pharmacy to distinguish among the different formulations for children, adolescent, and adult patients. Pharmacy staff can also purchase age-specific formulations of the same vaccine from different manufacturers to make them easier to identify, ISMP noted.


2)Confusion between siblings, leading to wrong patient errors. Place siblings in separate rooms or vaccinate one child at a time. Only bring in one child’s vaccines to the treatment room at a time. With multiple vaccines, separate them on different trays. Always verify the patient with the patient’s name and age before vaccine administration.

3) Missed opportunities to vaccinate. Caregivers/parents should be given immunization schedules so that they know when vaccinations are due. If vaccines are missed, a catch-up immunization schedule should be created and given to the caregivers/parents. Try to post immunization schedules for staff to refer to. Link the immunization schedule to the electronic medical record (EMR) or immunization record. Build an alert into the EMR to remind staff about upcoming immunizations to discuss with patients. Consider adding an ambulatory clinical pharmacist to the healthcare team in pediatric primary care and public health clinics to help with safe immunization practices.

4) Errors in route of administration. Use the Immunization Action Coalition chart for easy reference verification of the route of administration for all vaccines. Add the route of administration of vaccines to the medical record, using bold typeface.

5) Combination vaccines and diluent errors. In the medical records and vaccination records, use brand names and list all components of combination vaccines. To reduce the risk of diluent errors, only use the vaccine diluents supplied and packaged by the manufacturer for those vaccines needing reconstitution. Consider labeling the diluents to distinguish from the vaccine. Document the specific NDC number, lot number, and expiration date of each vial in the vaccination record before administration of the vaccine. Document administration of the vaccine after the task.

6) Errors due to vaccine nomenclature. With long generic drug names, highlight the brand name with a highlight marker or circle. Similar vaccine names should be distinguished in the medical record by highlighting differences in the names, starting with the brand name and then the generic drug name. Prescribe vaccines with look-alike generic names by using the brand name. List the full vaccine names-do not abbreviate or use informal names.

7) Errors due to labeling and packaging. Medications for newborns and mothers should be stored in separate areas of the hospital or birthing center. Consider administering newborn medications in a different area than the mother. To avoid look-alike vaccine mix-ups, buy vaccine products from different manufacturers. Store vaccines with similar packaging in different refrigerators or freezer areas. Label all vaccines that are prepared.

8) Vaccine storage problems. Refer to the CDC toolkit for vaccine storage and handling to ensure proper storage equipment is used and temperature range and monitoring is addressed. Organize vaccine vials and syringes into bins or other containers by vaccine type and formulation.

For vaccine clinics, do not draw a single vaccine or batches into syringes until time of administration. Consider using commercially available prefilled and labeled syringes of vaccines, if possible.

9) Expired vaccines. Do not administer expired vaccines. Vaccine stock should be checked regularly for expired products and removed from unexpired stock. Soon-to-expire products should be used first.

10) Patient should be involved in the vaccination verification process. Give patients, parents, and legal guardians the CDC vaccine information sheet for review prior to the administration. Document this in the patient medical record. Link the Vaccine Information Sheet to the electronic medical record or vaccination record. Talk to patients about the specific vaccines to be administered and answer any questions. Remind patients that young children may develop a fever after vaccinations are administered. Prophylactic acetaminophen is not recommended by the CDC Advisory Committee on Immunization Practices.