COVID Vaccine Administration Problems Top ISMP’s List of Medication Safety Concerns from 2021

Of the 10 medication safety issues listed, four of them concern Covid-19 vaccinations directly.

A new report issued by drug safety experts warns that several of the most concerning medication errors last year involved potential problems with COVID-19 vaccine vaccine administration, including confusing the vials with other medications.

The Institute for Safe Medication Practices (ISMP) issued a press release last month, which outlined the top 10 medication errors and hazards that were covered in its widely regarded newsletter in last year, ISMP’s Medication Safety Alert! Acute Care.

Though the list was not specifically focused on Covid-19, 40% of the errors involved COVID vaccine administration problems, with fatigue of overworked, overwhelmed, and understaffed healthcare workers, combined with unlabeled and look-alike vials and syringes leading to to numerous Covid-19 vaccine problems over the last year. These vaccine errors, along with other safety concerns that include the lack of medication safety officers in U.S. hospitals and unsafe practices with shared glucometers and insulin pens, were covered in reports published by the non-profit group.

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The Covid-19 vaccine administration problems presented in the ISMP list focus mainly on the Pfizer-BioNTech injections and the similarity of the glass vial packaging to other medications. The confusion apparently occurs once colored caps and labels that identify age-specific formulations of the vaccine are removed from the vials before they are administered. This has resulted in age-specific formulations being given to children of the wrong age.

Some medical mistakes reported involved the unintentional injection of epinephrine instead of the Covid-19 vaccine, due to the similar look of the pre-drawn syringes. During vaccine administration, epinephrine is on hand in case of an anaphylactic reaction. When both medications are drawn in their respective syringes and are close together health care workers have had difficulty telling them apart, leading to the patient receiving the wrong injection.

Additionally, the ISMP list presents common mix-ups over the last year, where both labeled and unlabeled syringes of the Pfizer-BioNTech vaccine have been confused with those for the influenza vaccine. As health authorities highly recommend that both vaccines be administered together, this has resulted in health care workers mistakenly administering the wrong vaccine due to difficulty telling them apart once drawn into a syringe. This difficulty is compounded by syringes being in close proximity in the vaccination area as well as interruptions and distractions before the shots are given.

Other common medication errors outlined by ISMP in 2021 included errors and delays linked to the use of hypertonic sodium chloride, due to mix ups with sodium chloride; errors involving discontinued high-alert medication infusions which were accidentally restarted, resulting in severe injuries and patient deaths; reusing glucometers, fingerstick devices and insulin pens which led to infection transmissions; adverse glycemic event errors involving mix-ups of insulin names or vials; the lack of safety medication officers at U.S. hospitals; and failures to report medication errors, which can help prevent future medication hazards and errors and help to create prevention strategies.

According to the ISMP, the list of medical mistakes and errors presented in the press release “could be avoided or minimized with system and practice changes attainable by all healthcare providers.” Similar system and practice issues cause more than 100,000 reports of medication errors received by the U.S. Food and Drug Administration (FDA) each year. These medical mistakes often result in medical malpractice claims due to the injuries they cause such as hospitalization, disability, birth defect, life-threatening situations, and even death.


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