During the flu season, some hospitals provide boxes of influenza vaccine to the emergency department (ED) and nursing units to store in their unit-based medication refrigerator to facilitate vaccine distribution. Although we would much rather see patient-specific doses dispensed from the pharmacy, if your facility does this, you need to be certain that there are no other refrigerated look-alike items (with container volume, shape, color, or labeling) with which the vaccine might be confused.
Just over 2 months ago, we published an article about a measles vaccine diluent that was confused with atracurium, which resulted in the deaths of 15 children in Syria. But we also listed similar mix-ups between neuromuscular blockers and influenza vaccine in the US, at least one of which was a fatal event. All of these products were stored near one another in hospital refrigerators. In addition, we’ve received multiple reports of influenza vaccine being mixed up with insulin, and, just last month, with tuberculin purified protein derivative (PPD), which led to 41 correctional officers receiving intradermal injections of influenza vaccine (www.ismp.org/sc?id=454).
While look-alike packaging can contribute to errors, nomenclature issues can also arise. We just learned about a close call in which boxes of DEFINITY (perflutren lipid microspheres), used for cardiac imaging, were stored in an intensive care unit (ICU) refrigerator where influenza vaccine was normally kept during the flu season. The “perflutren” nomenclature, which contains the syllable “flu,” confused some staff, who initially thought it might be a new brand of influenza vaccine. It’s unclear why Definity would need to be stored in a nursing unit refrigerator, but it was. We’ve also seen this when visiting hospitals as safety consultants. Instead of storing Definity on nursing units, cardiac staff should bring it with them for bedside echocardiograms. The bottom line is to check on how medications and vaccines are stored in refrigerators to prevent mix-ups form occurring. Also, the importance of barcode scanning prior to administration can’t be overemphasized as a way to reduce these types of errors.