Two patients receive EPINEPHrine instead of COVID-19 vaccine

At a coronavirus disease 2019 (COVID-19) vaccination site, the first two patients among 11 scheduled patients were accidentally given an EPINEPHrine injection instead of the Moderna COVID-19 vaccine. According to anaphylaxis guidance from the Centers for Disease Control and Prevention (CDC), EPINEPHrine should be readily available to treat anaphylactic reactions to the COVID-19 vaccines. At the vaccination site, there were two plastic bags: one with 11 predrawn syringes of vaccine (0.5 mL), and the other bag held two predrawn syringes of EPINEPHrine (0.3 mg/0.3 mL). The nurse initially took syringes from the bag holding the EPINEPHrine and accidentally administered them to the first two patients, then used the syringes from the other bag for the remaining patients, ending with two extra doses of the Moderna vaccine.

The vaccination site identified several contributing factors. The two light-protecting bags were close to each other and within arm’s reach of the vaccinating nurse. Both bags had the appropriate labels affixed, but the nurse thought the syringes all contained the vaccine. It is easy to see how that can occur since all the prefilled syringes looked similar. After the erroneous EPINEPHrine injection, one patient reported feeling tachycardic (which, at first, was attributed to the stress of vaccination). Neither patient suffered any lasting or serious adverse effects.

We recommend that COVID-19 vaccination sites stock only EPINEPHrine autoinjectors rather than using predrawn syringes of EPINEPHrine. The EPINEPHrine autoinjector looks visually different than predrawn vaccine syringes and, with training, is very easy to use in an emergency. Doses of EPINEPHrine and vaccine should be kept in different storage locations but close enough to the vaccinators so they can be easily and rapidly retrieved as needed. Consider storing the EPINEPHrine autoinjectors in an anaphylaxis kit with a tear-off lock.