Top vaccination errors-and how to avoid them

September 9, 2016

Administering the wrong vaccine and vaccinating someone of the wrong age are the most common vaccination errors, according to a new report from the Institute for Safe Medication Practices (ISMP) National Vaccine Errors Reporting Program (VERP).

Administering the wrong vaccine and vaccinating someone of the wrong age are the most common vaccination errors, according to a new report from the Institute for Safe Medication Practices (ISMP) National Vaccine Errors Reporting Program (VERP).

Over the past four years of tracking errors from outpatient settings, ISMP found that the wrong vaccine accounted for 23% of all errors. This was followed by wrong age (20%); wrong vaccine dose (12%); extra vaccine dose (9%); and wrong vaccine interval (7%).

“Thirteen percent of all reported vaccine errors were due to confusion that arose between numerous age-dependent vaccines that target the same diseases, particularly with influenza virus vaccines, hepatitis A and B vaccines, and various combination vaccines that target diphtheria, tetanus, and pertussis,” ISMP said in its July 28 Acute Care ISMP Medication Safety Alert!

Another 13% of the errors involved lack of familiarity with the recommended ages for various vaccines or a failure to take a step as simple as verifying the patient’s age prior to administration, ISMP wrote. The measles, mumps, rubella and varicella (MMRV) vaccines joined those previously mentioned as one of the most frequently involved in these types of errors.

Similar vaccine abbreviations and labeling or packaging, and dense storage conditions, played a role in the remaining 12% of age-related errors, ISMP wrote.

Out of 1,754 reports received by ISMP, errors with influenza vaccines accounted for 20% of all reports. This was followed by the Diphtheria and Tetanus Toxoids, Acellular Pertussis Adsorbed and Inactivated Poliovirus (DTaP-IPV) at 12%; hepatitis A vaccines at 10%; and Tetanus Toxoid, Reduced DiphtheriaToxoid, and Acellular Pertussis Adsorbed (Tdap) at 9%.

“Influenza virus vaccine…does not have distinct adult and pediatric formulations. Some formulations are indicated for both children and adults within certain age ranges,” ISMP wrote. “Given this and the high frequency of administration in all age groups, it is not surprising that influenza virus vaccine was the most common type of vaccine implicated in age-related errors among vaccines with age-dependent formulations.”

 

As a result, vaccine manufacturers must continue to improve labeling and packaging to differentiate age-dependent formulations of the same vaccine, according to ISMP. FDA and manufacturers should also “strongly consider seeking a federal regulatory change that allows the vaccine brand name to be listed first on vaccine labels, before the full generic names, which are often long and confusing. “

The ISMP provided additional tips for health practitioners to avoid vaccine errors:

  • Investigate purchasing different age-specific formulations of the same vaccine from different manufacturers to help distinguish them. If possible, stock only one manufacturer’s adult and pediatric/adolescent formulations of the hepatitis A and the hepatitis B vaccines (both adult and pediatric/adolescent formulations from the same manufacturer have the same strength).

  • Affix auxiliary warning labels to vaccines when first received in the clinic, medical office, or pharmacy to draw attention to products with different formulations for neonatal, pediatric, adolescent, and/or adult patients. Affix auxiliary labels to select vaccines with problematic similar names to draw attention to key information that would help promote selection of the correct product.

  • Maintain up-to-date easy-to-read electronic immunization schedules for infants, children, teens, and adults, and post them in clinical areas where vaccinations may occur.

  • Separate pediatric and adult formulations of vaccines in storage areas.

  • Prior to prescribing, dispensing, or administering a vaccine, verify the patient’s age by asking the patient or caregiver for a birth date and referencing the patient’s health record, immunization record, and/or medication administration record (MAR).