Preventing Preventable Vaccine Administration Errors in Your Medical Setting

June 2020

Technically Speaking
Monthly Column by Deborah Wexler, MD
Deborah Wexler MD
IAC Executive Director Dr. Deborah Wexler writes Technically Speaking, a column featured in each issue of Vaccine Update for Healthcare Professionals, the monthly e-newsletter from the Vaccine Education Center (VEC) at the Children’s Hospital of Philadelphia. Technically Speaking columns cover practical topics in immunization delivery such as vaccine administration techniques, storage and handling, contraindications and precautions, and scheduling.
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Preventing Preventable Vaccine Administration Errors in Your Medical Setting
Published June 2020
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 and/or multiple patients. 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 eleven preventable errors and, for each one, provides advice on:

  1. how to prevent the error and
  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

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