Technically Speaking: Preventing Preventable Vaccine Administration Errors in Your Medical Setting

It’s a dreaded scenario. Suddenly one of your staff members comes into your office and says, “We have a problem. We’ve given the wrong vaccine to one of our patients.” Or even worse, they might begin to describe errors with multiple vaccines or multiple patients or both. No one ever wants this scene to play out in their medical setting. So how do you prevent these preventable errors?

One way to prevent errors is to have everyone involved in vaccine administration in your healthcare setting review IAC’s educational handout, Don’t Be Guilty of These Preventable Errors in Vaccine Administration. Some of the mistakes highlighted on this four-page handout have more serious consequences than others, but none of these preventable errors should occur.

This practical tool lists 11 preventable errors and, for each one, provides advice on:

1. How to prevent the error
2. Helpful resources that can be consulted for further information

As detailed on the handout, are any of these preventable errors occurring in your practice?

• Not using a standardized checklist to screen patients for contraindications and precautions to vaccination
• Administering the wrong vaccine due to similarities in vaccine names (e.g., DTaP for Tdap, zoster for varicella, PPSV23 for PCV13)
• Using the wrong diluent or administering the diluent only
• Administering a vaccine after the expiration date
• Administering vaccine in the wrong site or by the wrong route
• Giving a vaccine dose earlier than the recommended age or interval
• Giving two doses of live injectable or nasally administered vaccines too close together (leading to potential interference between these vaccines)
• Giving the wrong dosage amount for the patient’s age (e.g., influenza, hepatitis A, and hepatitis B vaccines)
• Giving both pneumococcal vaccines PPSV23 (Pneumovax^®) and PCV13 (Prevnar 13^®) on the same day
• Administering a vaccine outside of its ACIP-recommended age/dose schedule (e.g., DTaP-IPV, MMRV)
• Administering a vaccine using the wrong needle length

Your patients count on you to administer vaccines safely, effectively and correctly. All of these errors can be prevented with forethought and perhaps additional staff training. So DO be guilty of correcting these potential problem areas in your medical setting. And remember, the old saying is true: Prevention is indeed the best medicine — for both you and your patients.

Other helpful vaccine administration resources

• ACIP’s General Best Practice Guidelines for Immunization
• CDC’s e-Learn: Vaccine administration
• IAC’s vaccine administration handouts gateway page
• IAC’s clinic tools: Administering vaccines gateway page
• IAC PowerPoint handout: To Err Is Human; Not to Err Is Better! Vaccination Errors and How to Prevent Them. Slide presentation available upon request when visiting this IAC’s PowerPoint slide set webpage
• ISMP National Vaccine Errors Reporting Program: One in Three Vaccine Errors Associated with Age-Related Factors