News Release

ISMP Draws Attention to Age-Related Vaccination Errors

While there has been intense focus on COVID vaccine safety during the global pandemic, errors with other vaccines continue to increase the risk of disease outbreaks, costly overvaccination, and loss of public confidence in vaccines and the healthcare delivery system. The 2022 analysis by the Institute for Safe Medication Practices National Vaccine Errors Reporting Program (ISMP VERP) addresses this issue by focusing on vaccines outside of those intended to prevent COVID, and offers safe practice recommendations. 

ISMP found that during the 19-month timeframe examined, some of the most frequent types of vaccine-related events (excluding COVID vaccines) included age-related errors, which often are associated with administering the wrong vaccine or the wrong dose. Wrong age plus wrong vaccine or dose errors contributed to nearly half (46%) of all non-COVID vaccine errors reported to the ISMP VERP during that time.

Wrong age formulation and wrong dose errors occurred frequently between age-related formulations of influenza virus vaccines (31%), diphtheria, tetanus, and acellular pertussis vaccine (DTaP) (23%), hepatitis A vaccines (16%), and hepatitis B vaccines (16%). Unfortunately, the frequency of mix-ups between age-related formulations of these four vaccines has not improved much during the past decade.

ISMP’s safe practice recommendations to prevent age-related vaccine errors include:

  • Maximize technology. Utilize clinical decision support and barcode scanning, and develop order sets based on the Centers for Disease Control and Prevention (CDC) immunization schedules to guide prescribers to the appropriate age-based formulations.
  • Streamline purchasing. Investigate purchasing differing age-specific formulations of the same vaccine from different manufacturers to help distinguish them.
  • Store separately. Separate vaccine storage on different shelves in bins, ensure that they are properly labeled, and do not store vaccines with similar names, abbreviations, or overlapping components near each other.
  • Verify identity, age, and vaccine(s) requested. When checking in a patient scheduled to receive vaccine(s), ask the parent, caregiver, or patient to provide at least two patient identifiers—their full name and date of birth. Verify age and which vaccine(s) they requested.
  • Label syringes. Clearly label all syringes that do not come prefilled; print labels for each patient or provide practitioners who prepare vaccines with strips of preprinted labels that differentiate formulation and dose for each patient.
  • Engage the patient. Involve the patient and their caregiver or parent in verifying vaccine, formulation, and dose by reviewing the label.
  • Document the vaccine(s). Document the lot number and expiration date prior to administration. This is often the step where errors can be detected and mitigated.
  • Educate practitioners. Educate staff about new vaccine products and when adding new vaccines to formulary, provide resources listing indication and vaccine schedules, share impactful stories, and print ISMP’s table (www.ismp.org/ext/55) as a teaching tool.

ISMP also has encouraged manufacturers and the U.S. Food and Drug Administration (FDA) to review labeling strategies to reduce the risk of age-related vaccine mix-ups. One recommended strategy is to prominently display PEDIATRIC or ADULT formulations in a different color on the top of the cartons, vials, and on syringe labels.

For a copy of the September 12, 2022, ISMP Medication Safety Alert!® Acute Care newsletter cover article with more details and the full list of recommendations, visit: https://www.ismp.org/node/39582

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