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ISMP identifies non-COVID-19-related vaccine errors
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ISMP identifies non-COVID-19-related vaccine errors

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Vaccine Errors

Ariel L. Clark, PharmD

In a recent report published by the Institute of Safe Medical Practices (ISMP), more than 1,400 vaccine-related errors were reported and analyzed within the ISMP National Vaccine Errors Reporting Program (ISMP VERP) during a 19-month period from June 2020 to December 2021. The types of errors categorized in the report—32% unrelated to the COVID-19 pandemic—can be categorized into subgroups in order to help health care providers best learn how to avoid them in practice.

Age-related non-COVID-19 vaccine errors

Analysis of age-related vaccine errors by ISMP encompassed several subgroups of error types including wrong dose and wrong vaccine. These 2 error types accounted for 33% of all the non-COVID-19–related vaccine errors during the 19-month period analyzed by ISMP.

The final age-related vaccine errors analyzed in this report were the wrong age subgroup. While this report did not detail if this meant a dose was too low or too high, both instances can have negative consequences for the patient.

Authors of the report note that receiving a dose too low can leave the patient at risk of lower-than-ideal protection from illness, while receiving a dose too high for a patient's age can lead to increased risk of adverse events and can require additional monitoring for potentially dangerous adverse effects.

Vaccinations most likely to be related to age-related errors

ISMP further analyzed the age-related vaccine errors to determine which vaccinations were connected to the errors. The most common immunizations that incurred an age-related error, according to the report, were influenza; diphtheria; tetanus; and/or pertussis combinations, hepatitis A, and hepatitis B vaccines. ISMP noted that these 4 vaccines have occurred with similar frequency as compared to earlier VERP analytic reports; namely, those from 2012, 2014, and 2017.

The root cause of the errors related to these vaccines also remained similar to previous reports. The most commonly identified reason was the struggle to differentiate between “age-dependent formulations of the same vaccine,” which accounted for 44% of the errors related to the 4 previously mentioned vaccinations.

ISMP noted that similar packaging and labeling between adult and pediatric doses cause major confusion for practitioners because they can have the same or similar names, colors, etc.

Vaccine-specific errors

A second grouping of vaccine errors identified in the 2022 report were related to the wrong vaccine being administered. These errors most often occurred in age-specific formulations, including those for diphtheria, tetanus, and/or pertussis combinations as well as influenza, meningococcal, measles, mumps, rubella and/or varicella vaccines. Unsurprisingly, the same root cause associated with age-related vaccines occurred in the majority of these cases, followed by storage of vaccine products near one another, thus increasing the likelihood of administering the wrong vaccine into a patient.

Best practices for avoiding vaccine-related errors

Maximizing technology encompasses a broad span of opportunities to reduce errors. According to the report, technology can be used to produce order sets, implement barcode scanning, and coalesce generic and brand-name entries in electronic health records to help limit confusion. Ordering age-dependent vaccines from alternate manufacturers and changing storage patterns can also help minimize errors.

ISMP identifies non-COVID-19–related vaccine errors

The ISMP report notes that this can also help ensure that sound-alike/look-alike drugs and similarly packaged drugs are not as easily confused during fulfillment. Practitioners can also help to reduce errors by preparing documentation in advance of administration, properly labeling doses pulled from multidose vials, and by engaging and educating patients and fellow providers.

As vaccinations remain of vital importance to the protection of public health, health care practitioners can reflect on the 2022 ISMP VERP reports’ common findings related to vaccine errors and use the recommendations to help ensure that the right vaccine goes in the right patient, at the right time and at the right dose.



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