News Release

ISMP Analyzes First Few Months of COVID-19 Vaccine Errors

Since COVID-19 vaccines were granted emergency use authorization, The Institute for Safe Medication Practices (ISMP) has received reports of errors related to storage, preparation, and administration. Because COVID-19 vaccine errors can result in reduced effectiveness, and other safety implications, ISMP is sharing learning from those errors and making safe practice recommendations.

It is mandatory to report errors with COVID-19 vaccines to the federal Vaccine Adverse Event Reporting System. Healthcare practitioners also have voluntarily reported to ISMP to help communicate about potential safety issues. An analysis of errors from the last four months of vaccinations was published in the April 22, 2021 issue of the ISMP newsletter along with suggested prevention strategies. Category types include:

  • Wrong dose, age, or administration technique—includes dose mismeasurement, reuse of empty syringes or needles, and administering to patients younger than allowed age range

  • Wasted vaccine—excluding diluent errors, includes leakage or insufficient dose left in vial

  • Incorrect storage and handling—such as administration of expired vaccine or temperature excursions

  • Contraindicated coadministration—within 90 days of monoclonal antibodies or 14 days of non-COVID vaccine

  • Mixed vaccine series—incorrect mRNA vaccine administered for second dose

  • Wrong time interval—second dose given at wrong interval or third dose administered

  • Wrong volume of diluent, no diluent, or wrong diluent—leading to wrong dose and waste

  • Confusing vaccine cards—two dose vaccine card shipped with one dose vaccine

For a copy of the full ISMP newsletter article, visit: Any New Process Poses a Risk for Errors: Learning from 4 Months of Coronavirus Disease 2019 (COVID-19) Vaccinations. Access may require free registration.   

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Since the 2021-2022 influenza (flu) vaccine became available in September, the Institute for Safe Medication Practices (ISMP) has received multiple reports of mix-ups. Some patients have consented to a flu vaccine but received one of the COVID-19 vaccines instead, while others have received the flue