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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:
- Look-alike names, labels, packaging
- Unsegregated storage in a refrigerator
- Mixing errors or omissions with 2-component vaccines
- Miscommunication
- Not checking/documenting administration in the immunization
information system (IIS)
- Lack of usual procedures/technologies during mass immunizations
- Temperature excursions and expired vaccines
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.
References:
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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