Best Practices to Prevent Vaccination Errors

Vaccine errors have always occurred, but an increased demand for vaccines and workforce shortages have increased the possibility for errors at the pharmacy. Historically, the most common vaccination errors are the wrong vaccine, the wrong age for vaccination, and the wrong vaccine dose. Most errors occur due to lack of time, being rushed, impatience, lack of staffing, or everyone showing up at the same time or when the pharmacy is about to close.

“It is so easy to skip steps and think you have done this 1000 times, so what could go wrong? The best advice is to approach each vaccination with care,” said Simona Dorf, PharmD, BCMAS, clinical pharmacist manager for First Databank. “Check the vaccine administration record form carefully before mixing or drawing up the vaccine and scan the barcodes to ensure the same vaccine that is billed is being prepared for administration.”

Jay Phipps, PharmD, president and CEO of Phipps Pharmacy in Jackson, Tennessee, noted administration technique–related vaccination errors have increased recently. These include shoulder injuries related to vaccine administration, use of the wrong needle size, and the administration of a dose lower than authorized.

Limiting Mistakes

Numerous safeguards can be put in place to keep vaccination errors from happening, such as creating physical barriers for vaccine storage. Phipps noted the importance of developing a plan for vaccine storage in refrigerators and freezers that is well organized and properly labeled.

“The plan should include separating vaccines,” he said. “Pediatric, adult, and adult over 65 vaccines should be stored in separate, labeled plastic bins of different colors. All individual syringes containing vaccines should be clearly labeled for each patient. If doses are being drawn up in advance without patient specifics, then each syringe should be labeled with [the] name of vaccine, date, and time.” Additionally, Phipps noted that, if the pharmacy management system allows, barcode scanning should be confirmed for the correct vaccine.

One overlooked vaccine error can result from inappropriate vaccine storage. The CDC recommends storing vaccines in separate, self-contained units that only refrigerate or only freeze. If a combination refrigerator/freezer must be used, only refrigerated vaccines should be stored in the unit, and a separate standalone freezer should be used for frozen vaccines.

Avoiding Vaccination Errors

Another thing that can help eliminate errors is utilizing a separate area for vaccine preparation. “ [Preparation and] administration should be in a separate area away from distractions and interruptions,” Phipps said. “Reference material should be posted that includes vaccines dilution requirements, if applicable; storage; route of administration; and length of needle for each vaccine at the pharmacy. A Do Not Disturb sign is also recommended when vaccines are being prepared or administered.”

“Immediately prior to administration, the patient’s name, date of birth, vaccine type, and number [of] shot in [the] series should be confirmed,” Phipps said. “[Although] the workload of all pharmacy staff is significant, the short amount of time to confirm the information is insignificant in comparison [with] the potential for error.”

Vaccine Delivery

If a pharmacist is making travel vaccine recommendations, they must carefully review the patient’s travel itinerary and pay particular attention to not only the country to which the person is traveling but also the exact region of the country. “Vaccine recommendations might vary from city to rural area,” Dorf said.

In a perfect world, vaccines would be scheduled in a dedicated block of time each day, with adequate staff to provide the vaccinations, said Phipps. Staff would be responsible for only vaccine delivery and would not be dispensing at the same time. However, he doesn’t know anyone who practices in that bubble.

“Distractions from patients, coworkers, telephone calls, [and] the constant barrage of alerts we receive from social media are commonplace,” he said. “[Although] most professional pharmacy staff are not actively using their personal phone while involved in vaccine preparation or in direct patient care, it is not uncommon for them to glance at messages or alerts on smart watches. Each time our focus is taken from the patient, the risk of error increases.”

Reference

1. Vaccine administration: preventing vaccine administration errors. CDC. January 5, 2021. Accessed March 7, 2022. http://www.cdc.gov/vaccines/hcp/admin/downloads/vaccine-administration-preventing-errors.pdf