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Have You Committed Any of These Common Pharmacy Vaccination Errors?

Top 10 Vaccination Errors (And How To Prevent Them) by Elements magazine |

January 17, 2019

Inside: A recent industry report revealed the most common immunization errors. Here’s how to prevent them in your pharmacy.

Vaccine programs are an important source of revenue for many independent community pharmacies. According to the 2018 NCPA Digest, 70 percent of independent pharmacies offered immunizations in 2017. But introducing vaccines to your repertoire comes with a risk for errors.

The Institute for Safe Medication Practices (ISMP) partnered with the California Department of Public Health to develop a national vaccine-error reporting system to collect data to share with the FDA and CDC’s Vaccine Event Reporting System (VAERS). Using this data, ISMP released a report identifying the eight most common vaccine-related errors.

This was the second report of its kind, and 2017’s data showed little improvement over the original data from 2012. In short: we’re still making the same mistakes.

Here are the errors ISMP identified, and tips for preventing these mistakes at your pharmacy.

1. Wrong vaccine

Giving patients the entirely wrong vaccine accounted for 23 percent of reported vaccine errors in 2017. Many of these can be attributed to similar brand and generic names, abbreviations, and vaccine labels or packaging.

Several common vaccines were frequently confused, so give special attention to these products:


The ISMP recommends storing vaccine vials and syringes separately in bins or other containers according to vaccine type and formulation. Never store vaccines and syringes together. Consider additional labels for frequently confused vaccines.

2. Wrong dose

The biggest culprit for incorrect dosage is age-dependent formulations of the same vaccine. Hepatitis A, DTaP-IPV, and influenza are examples of common immunizations with doses that vary based on age.

Take the following steps to prevent incorrect dosing:


3. Expired vaccines or contamination/deterioration

Vaccine storage is crucial to treating patients effectively and protecting the investment you’ve made in these products. Discovering a vaccine is expired or contaminated before it’s administered is better than the alternative, but it still costs you money. Take these steps to ensure you’re always storing vaccines properly.


4. Wrong age

Because children, adults, and seniors all have different immunization needs, it’s important to make sure you’re following appropriate guidelines.

Along with preventing incorrect doses, verifying a patient’s date of birth can prevent immunizing a patient who’s too young or too old for that vaccine. Be aware of recommended immunization schedules for children and adolescents and adults. Consider hanging up a poster or cheat sheet for reference.

5. Wrong time or interval

The report said just over half of vaccine interval errors were associated with not checking the patient’s chart to confirm the date of the prior vaccine. Training employees to include this crucial step in every immunization can prevent these errors.

The other cited factors in vaccine interval errors are a bit harder to control, as they may fall on a patient’s previous healthcare providers, the patient, or their parent/guardian:


However, pharmacists can take steps to prevent those errors from recurring and leading to errors down the road:


6. Vaccine/component omission

Just as with vaccine interval errors, vaccine omissions (or duplications) are caused mostly by a failure to check a patient’s chart or vaccine registry.

In other cases, patients were administered diluents without the active vaccine components or administered just one component of a two-component vaccine. The majority (77 percent) of these errors involved Pentacel. Menveo was also mentioned in the reports. The report recommends these steps to avoid problems:


7. Wrong route

Should this vaccine be delivered via intramuscular, subcutaneous, oral, intradermal, or intranasal methods? The answer isn’t always obvious when dealing with vaccines that come in multiple route for a variety of patients.

Though the data described just two percent of vaccine errors as incorrect route, some preventative measures could make that number even smaller.


8. Wrong patient

Mixing up patients is surprisingly easy, but so is guarding against this kind of mistake. Avoid a serious error with common-sense safeguards.


Vaccine errors continue to trouble the healthcare industry, but you can prevent them at your pharmacy. Make smart changes to your protocols to keep your patients healthy.



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