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What’s New in the Patient Safety World

December 2020

ISMP Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines



As the world waits with bated breath for mass vaccinations to protect against the COVID-19 coronavirus, ISMP (Institute for Safe Medication Practices) reminds us of the many types of errors that might occur related to vaccinations (ISMP 2020). We discussed some of these in our November 19, 2019 Patient Safety Tip of the Week “An Astonishing Gap in Medication Safety”. In that column we noted cases where insulin or neuromuscular blocking agents (NMBA’s) were erroneously given instead of intended vaccines, usually with disastrous results. We did discuss some of the root causes and important lessons learned and recommendations for what you should be asking at your organization or facility.


ISMP (ISMP 2020) discusses factors in the following categories related to adverse vaccination-related events:


ISMP then provides solid recommendations on planning vaccination campaigns, safe vaccine storage, staffing and training, safe vaccine dispensing. safe vaccine administration, patient education, and reporting adverse vaccine events.


These recommendations are important regardless of what type of vaccinations you are providing. But they take on even greater significance knowing that several hundred million Americans will soon be getting vaccinated to prevent COVID-19, many requiring more than one dose. Now is a good time to begin preparing your staff and organization for this anticipated surge. This ISMP article is a great place to start.






ISMP (Institute for Safe Medication Practices). Learning from Influenza Vaccine Errors to Prepare for COVID-19 Vaccination Campaigns. ISMP Medication Safety Alert! Acute Care Edition 2020; 25(23): November 19, 2020






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