News Release

ISMP Releases Biannual Report on Vaccination Errors

As this year’s flu season is underway, and vaccination programs are seeking to achieve high immunization coverage, more needs to be done to reduce the risk of vaccination errors. The Institute for Safe Medication Practices (ISMP) recently released its 2017-2018 Biannual Report of the ISMP National Vaccine Errors Reporting Program (VERP), which analyzes reported events involving how vaccines are being handled and administered, discusses possible contributing factors to errors, and provides risk reduction strategies.

The report summarizes the findings from analysis of 1,143 events summitted to the ISMP VERP from January 2017 through December 2018. Highlights of the analysis include:

  • Most reported errors with vaccines reach the patient, as opposed to being a near miss or hazardous condition.

  • Most of the reported errors occurred in medical clinics, physician practices, hospital (ambulatory) and public health immunization clinics.

  • Overall, errors with influenza virus vaccines (Trivalent and Quadrivalent, Types A and B) were reported most frequently.

  • The five most commonly reported types of errors involving vaccines were: wrong vaccine administered, wrong age (i.e., patient not correct age for vaccine being given), extra dose, and expired vaccine.

  • Nearly one-third of reports regarding an extra dose of vaccine administered involved failure to check the patient’s vaccine history, while another almost 20% involved failure to check the state vaccine registry before administration.

  • More than half of the events involving administration of the wrong vaccine were associated with similarities in vaccine names, abbreviations, or labeling/packaging. About a third involved diphtheria, tetanus and/or pertussis vaccines (Tdap, DTaP, DT, Td and combination vaccines); although approved for different indications and/or populations, their abbreviations differ only by upper or lowercase letters.

  • To reduce the risk of vaccination errors and improve patient safety, ISMP recommends that healthcare providers and manufacturers adopt and layer multiple risk-reduction strategies. The vaccine annual report offers specific recommendations related to staff education, patient education, verifying immunization history, storage and handling of vaccines, specific considerations related to use of multi-vial vaccines, and preventing administration of expired vaccines. The report also provides recommendations for the Food and Drug Administration (FDA) and vaccine manufacturers.

For a copy of the report, click here (registration may be required). To report vaccine errors or near misses to ISMP’s VERP, go here.

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