Inside: A recent industry report revealed the most common immunization errors. Here’s how to prevent them in your pharmacy.
Vaccine programs are an important source of revenue for many independent community pharmacies. According to the 2018 NCPA Digest, 70 percent of independent pharmacies offered immunizations in 2017. But introducing vaccines to your repertoire comes with a risk for errors.
The Institute for Safe Medication Practices (ISMP) partnered with the California Department of Public Health to develop a national vaccine-error reporting system to collect data to share with the FDA and CDC’s Vaccine Event Reporting System (VAERS). Using this data, ISMP released a report identifying the eight most common vaccine-related errors.
This was the second report of its kind, and 2017’s data showed little improvement over the original data from 2012. In short: we’re still making the same mistakes.
Here are the errors ISMP identified, and tips for preventing these mistakes at your pharmacy.
1. Wrong vaccine
Giving patients the entirely wrong vaccine accounted for 23 percent of reported vaccine errors in 2017. Many of these can be attributed to similar brand and generic names, abbreviations, and vaccine labels or packaging.
Several common vaccines were frequently confused, so give special attention to these products:
- Diphtheria, tetanus, and/or pertussis vaccines (Tdap, DTaP, DT, Td, and combination vaccines)
- Measles, mumps, rubella, and/or varicella vaccines (MMR [M-M-R II], MMRV [PROQUAD], and varicella [VARIVAX])
- Hepatitis A (HAVRIX and VAQTA), hepatitis B (Engerix-B, Recombivax HB, and HEPLISAV-B), and combination vaccines (TWINRIX and PEDIARIX)
- Pneumococcal vaccines (PNEUMOVAX 23 and PREVNAR 13)
- Influenza virus vaccines (FLUZONE HIGH-DOSE, FLUZONE QUADRIVALENT, FLUARIX QUADRIVALENT, and FLULAVAL QUADRIVALENT)
The ISMP recommends storing vaccine vials and syringes separately in bins or other containers according to vaccine type and formulation. Never store vaccines and syringes together. Consider additional labels for frequently confused vaccines.
2. Wrong dose
The biggest culprit for incorrect dosage is age-dependent formulations of the same vaccine. Hepatitis A, DTaP-IPV, and influenza are examples of common immunizations with doses that vary based on age.
Take the following steps to prevent incorrect dosing:
- Make sure the entire pharmacy staff is familiar with the indicated ages for vaccines. Keep reference materials in a convenient location and encourage employees to double check when they’re not sure.
- Always verify the patient’s age, and include this step in any training or guidelines you create about protocol.
- When possible, purchase age-specific formulations of the same vaccine from different manufacturers to make them easy to distinguish.
- Separate adult and pediatric formulations of the same vaccine.
3. Expired vaccines or contamination/deterioration
Vaccine storage is crucial to treating patients effectively and protecting the investment you’ve made in these products. Discovering a vaccine is expired or contaminated before it’s administered is better than the alternative, but it still costs you money. Take these steps to ensure you’re always storing vaccines properly.
- Keep refrigerated vaccines between 36° and 46°F.
- Separate vaccine vials and syringes into bins or other containers according to vaccine type and formulation, and never store them together.
- When conducting offsite immunizations, plan for safe storage of single component vaccines and any associated diluents, and two-component vaccines, while away from the pharmacy.
- Routinely check supplies to make sure nothing is expired or in danger of expiring soon.
- Use the CDC’s toolkit for vaccine storage and handling for more guidance.
4. Wrong age
Because children, adults, and seniors all have different immunization needs, it’s important to make sure you’re following appropriate guidelines.
Along with preventing incorrect doses, verifying a patient’s date of birth can prevent immunizing a patient who’s too young or too old for that vaccine. Be aware of recommended immunization schedules for children and adolescents and adults. Consider hanging up a poster or cheat sheet for reference.
5. Wrong time or interval
The report said just over half of vaccine interval errors were associated with not checking the patient’s chart to confirm the date of the prior vaccine. Training employees to include this crucial step in every immunization can prevent these errors.
The other cited factors in vaccine interval errors are a bit harder to control, as they may fall on a patient’s previous healthcare providers, the patient, or their parent/guardian:
- Lack of documentation of prior vaccination in either the patient’s medical record or the vaccine registry
- Miscommunication of vaccine orders and ambiguous due dates
- Unfamiliarity with vaccine intervals
However, pharmacists can take steps to prevent those errors from recurring and leading to errors down the road:
- Make sure any staff members involved in vaccine activities know how to search the vaccine registry and how to document immunizations in the registry
- Keep accurate and clear records, and provide those records to patients
- Educate patients about when they are due for their next vaccination, and try to get patients to schedule the next dose at the end of the appointment
6. Vaccine/component omission
Just as with vaccine interval errors, vaccine omissions (or duplications) are caused mostly by a failure to check a patient’s chart or vaccine registry.
In other cases, patients were administered diluents without the active vaccine components or administered just one component of a two-component vaccine. The majority (77 percent) of these errors involved Pentacel. Menveo was also mentioned in the reports. The report recommends these steps to avoid problems:
- Make sure everyone involved in vaccines at your pharmacy is familiar with mixing and preparing these vaccines.
- Place vaccines with similar names or abbreviations or overlapping components away from each other in your storage area to avoid confusion.
- Develop a process to keep two-component vaccines together, and to keep diluents and their corresponding vaccines together when possible.
7. Wrong route
Should this vaccine be delivered via intramuscular, subcutaneous, oral, intradermal, or intranasal methods? The answer isn’t always obvious when dealing with vaccines that come in multiple route for a variety of patients.
Though the data described just two percent of vaccine errors as incorrect route, some preventative measures could make that number even smaller.
- Add auxiliary labels to vaccines that are prone to administration by the wrong route (like influenza or varicella) to draw attention to the correct route.
- Examine protocols for any vaccine you’ll be using during an immunization activity to confirm they include the route of administration. The Immunization Action Coalition (IAC) provides sample protocols (or standing orders) for most vaccines.
8. Wrong patient
Mixing up patients is surprisingly easy, but so is guarding against this kind of mistake. Avoid a serious error with common-sense safeguards.
- Check each patient’s chart and confirm their name and date of birth before administering any vaccines.
- Be particularly vigilant with siblings, who often come in together and share a last name. Take them back one at a time and bring in each vaccine separately.
- Whenever possible, use commercially available, prefilled syringes of vaccines—some reported “wrong patient” errors involved unlabeled syringes.
Vaccine errors continue to trouble the healthcare industry, but you can prevent them at your pharmacy. Make smart changes to your protocols to keep your patients healthy.
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