ISMP’s Safe Practices for Preventing COVID-19 Vaccine Error

Following distribution and administration of the Pfizer-BioNTech and Moderna COVID-19 vaccines, the Institute for Safe Medication Practices (ISMP) says there are repeat errors and hazards associated with the immunizations. ISMP has received numerous voluntary reports regarding adverse events via the ISMP National Vaccine Errors Reporting Program (VERP), the ISMP National Consumer Medication Errors Reporting Program and email correspondence with professional colleagues.

Based on this data, the Institute says healthcare providers should be informed of the six most commonly reported errors linked to the Pfizer-BioNTech and Moderna COVID-19 vaccines:

  • faulty dilution resulting in incorrect dosage;
  • mix up between vaccinations and the monoclonal antibodies used to treat mild to moderate COVID-19 infection;
  • waste of dosages due to faulty preparation, incorrect syringe selection and cancelled appointments;
  • administration to patients who aren’t of the appropriate age;
  • scheduling mishaps with the second dose; and
  • serious but not life-threatening allergic responses.

To prevent these adverse events, COVID-19 vaccine administrators are advised to adopt the following safe practices:

  • Select location with adequate space to assess individuals before and after the vaccination, while ensuring adherence to social distancing guidelines. Additionally, sites should be equipped with resources to treat patients who experience a reaction;
  • Provide staff education and verify competency regarding vaccine storage, preparation and administration, as well as recognizing and treating reactions that can occur;
  • Develop a pharmacy verification process for determining the vaccine quantity needed each day to prevent waste and allow for disbursement of prefilled, labeled syringes for daily vaccinations (if possible);
  • Implement a double check of the dilution process (if staffing permits);
  • Utilize separate storage space to house the different vaccines and monoclonal antibodies;
  • Create a reliable scheduling system that includes patient appointment reminders and a process for distribution of any leftover doses; and
  • Prepare for possible allergic reactions, including emergency equipment and medications readily available to staff.

View the detailed list of recommendations on the ISMP website.

Healthcare providers are reminded they must report all COVID-19 errors and adverse reactions to VERP. Administrators are also advised to encourage all vaccinated individuals to enroll in the V-safe program, the CDC’s smartphone-based monitoring tool that offers patients an easy mechanism for reporting reactions.

MLMIC has assembled a number of other critical resources to support New York physicians as they navigate the pandemic:

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