COVID-19 Vaccines
Loren Bonner
The Institute for Safe Medication Practices (ISMP) continues to track the errors that have been reported from the currently authorized COVID-19 vaccines.
With health care practitioners in the United States administering COVID-19 vaccines for months now, ISMP said it has analyzed more than 160 COVID-19 vaccine errors voluntarily reported to them between December 14, 2020, and April 15, 2021. In January 2021, they published an analysis of early vaccine errors from the Pfizer and Moderna COVID-19 vaccines. In late April 2021, ISMP issued an update in a new report.
Compared to ISMP’s January analysis, which reported dilution errors (Pfizer–BioNTech vaccine), wasted vaccine doses, administration to the wrong age group, and errors associated with scheduling second doses, the new report includes a wide variety of different error report types.
These include
- Administration of a dose lower than authorized.
- Administration to a patient younger than authorized.
- Administration using the wrong injection technique.
Michael Cohen, RPh, FASHP, president of ISMP, said they were surprised by the number of cases of shoulder injury related to vaccine administration.
“As a result of the pandemic, health professionals who may have it within their scope of practice to give vaccines may not have actually been properly trained,” he said. “They may not always properly locate the deltoid muscle and instead inject near the acromion, thus risking injection into a bursa or tendon.”
Some of these injuries are very painful and long lasting, sometimes even requiring surgery.
Cohen noted that they have also seen some error reports about accidental injection of air into the Pfizer vaccine vials.
He said the issue seems to be caused by taking multiple syringes out of their wrapper ahead of time, then drawing up 1.8 mL of air into the syringe in order to enter the vial of sodium chloride diluent and inject the 1.8 mL of air, which is also the volume of sodium chloride that will be removed to dilute the vaccine concentrate. “It will equilibrate the pressure inside the sodium chloride vial,” he said.
“Unfortunately, the empty syringe of 1.8 mL of air can be mixed up with filled syringes on a table and someone accidentally gives that syringe filled with air to the patient,” said Cohen. In addition, some syringes could contain vaccine that was never properly diluted, and patients could eventually be injected with undiluted vaccine.
ISMP also provides details on error types that are specific to the Pfizer and Moderna two-dose mRNA vaccines; dilution errors specific to the Pfizer vaccine; and errors specific to the Johnson & Johnson/Janssen vaccine.
They also note that errors reported to them do not reflect all COVID-19 vaccine errors that might be occurring nationally. “ISMP redacts and sends all of our reports to the FDA,” said Cohen. “We have not seen FDA or CDC issue any reports on COVID-19 vaccination errors that are based on ISMP VAERS data.”
The full report can be accessed on the ISMP website.