Preventive medicine: Be sure your staff is not making any of these frequently reported vaccine administration errors
Your patients count on you to administer vaccines safely, effectively and correctly. Unfortunately, vaccine administration errors occur too frequently in medical practices. Most of the time, these errors go unreported, or even worse, may not be recognized. Inadequate training in vaccine administration is a core problem for many medical practices.
To help elucidate the extent of the problem and to identify solutions, the Institute for Safe Medication Practices (ISMP), a nonprofit patient safety organization devoted to preventing medication errors and safe medication use, in collaboration with the California Department of Public Health, launched its Vaccine Errors Reporting Program (VERP) in September 2012. The VERP online error reporting system was created to allow healthcare professionals and patients to confidentially provide information about vaccine errors. By collecting and quantifying this information, ISMP determined it could better advocate at a national level for modifications (e.g., changes to similar vaccine names and labeling) that could reduce the likelihood of vaccine errors in the future. The information also could be used to teach about vaccine errors and how to avoid them.
VERP received 1,256 confidential reports of vaccine errors from September 2012 through June 2015. When these reports were broken down into categories, the two most commonly reported types of errors were (1) administering vaccine to the wrong-age patient and (2) administering the wrong vaccine to a patient. These two categories alone accounted for almost half of all reported errors.
What else can lead to vaccine administration errors? The frequency of errors reported to VERP is reflected in the percentages below:
- Wrong age: 24 percent
- Wrong vaccine: 24 percent
- Extra dose: 10 percent
- Too large a dose: 10 percent
- Expired vaccine: 8 percent
- Wrong interval: 7 percent
- Component omission: 5 percent
- Underdose: 5 percent
- Wrong patient: 4 percent
- Wrong route: 3 percent
To avoid vaccine errors in your practice setting, please make use of the resources below to train staff in how to avoid them. Remember, your efforts to apply preventive health measures for your patients include prevention of vaccine administration errors!
- Injection safety Web page
- ACIP General Recommendations on Immunizations
- Vaccine Administration chapter, Epidemiology and Prevention of Vaccine Preventable Diseases, 13th edition, 2015
- Provider's Role: Importance of Vaccine Administration and Vaccine Storage & Handling
- Vaccine Administration Web page
- Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines
- Slide set: Vaccine Administration: Frequent Errors and Prevention Strategies
- Hibbs, BF, et al. Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000-2013. Vaccine. 2015 Jun 22;33(28):3171-8.
- Notes from the Field: Rotavirus Vaccine Administration Errors — United States, 2006–2013 (MMWR, 2014, 63(4):81)
- Notes from the Field: Reports of Expired Live Attenuated Influenza Vaccine Being Administered — United States, 2007–2014 (MMWR, 2014, 63(35):773)
Where to Report Vaccine Errors