Vaccine administration errors: How to avoid

Influenza, zoster, hepatitis A, hepatitis B, and the diphtheria and tetanus toxoids and acellular pertussis adsorbed (DTaP) are among the most common vaccines involved in medication errors in the United States, according to a new report from the Institute for Safe Medication Practices (ISMP). The other most common problematic vaccines include Haemophilus influenzae type b conjugate, Tdap, DTaP-IPV, human papillomavirus (HPV4), and measles, mumps, rubella, and varicella (MMRV).

ISMP, which established the ISMP National Vaccine Errors Reporting Program with the California Department of Health in September, 2012, also found that unfamiliarity with the vaccine and mistakes in choosing age-dependent formulations of vaccines are among the most common factors in vaccine errors.

The other common contributing factors associated with vaccine errors include: failure to check or verify the patient’s age, health record, or state registry; similar vaccine names and abbreviations; similar and confusing vaccine labeling and packaging, unsafe storage conditions; and expiration dates not noticed or misunderstood.

“While the immediate impact of a vaccine-related error on a patient may not be serious, such errors may render the vaccine ineffective or reduce its effectiveness, leaving patients unprotected against serious diseases…,” ISMP wrote in the March 13, 2014, edition of ISMP MedicationSafetyAlert!

While vaccine errors are prevalent, the ISMP provides a number of recommendations for practitioners to safely administer vaccines. They include:

• Provide patients or caregivers with written information about vaccines, including the most current federal Vaccine Information Statement (VIS) in the patient’s native language.

• Establish standard protocols for frequently administered vaccines, to ensure consistency with vaccine administration.

• Require all healthcare professionals and assistants who immunize patients or handle vaccines to undergo periodic training and demonstrate competencies related to the types of vaccines being administered.

• Specify the storage requirements for each vaccine and diluents. Most vaccines must be stored in a refrigerator or freezer, and many require protection from light.

• Separate pediatric and adult formulations of vaccines in all storage areas and affix “Adult” or “Pediatric” labels to the vaccines and/or storage containers.

• Do not store vaccines with similar names or abbreviations (such as DTaP, DT, Tdap, and Td) immediately next to each other.

View the full list of ISMP’s recommendations for avoiding vaccine administration errors at: http://www.ismp.org/newsletters/acutecare/issues/20140313.pdf.