Vaccination Errors Continue To Be Public Health Concern: ISMP

The most frequent errors came from healthcare professionals giving patients the wrong vaccine, the ISMP reports.

New vaccines pose the greatest risk for medication errors, sometimes leading to patients receiving the wrong inoculation, according to a new report from a medical safety watchdog group.

Each year new formulas for influenza and COVID-19 vaccines are released by multiple manufacturers, along with various vaccines for respiratory syncytial virus (RSV) tailored for different age groups.

However, the Institute for Safe Medication Practices (ISMP) cautioned in its 2022–2023 Bi-Annual Vaccine Errors Report that new vaccine approvals and formula updates could lead to increased risks of errors.

ISMP is a non-profit organization that focuses on patient safety. The group works to prevent drug errors by conducting research, education and advocacy on how medication and vaccine errors pose a risk to the public and how to avoid those risks.

The group compiles a bi-annual report indicating the types of vaccine errors that occurred and where they occurred the most, and subsequently offers recommendations on how healthcare providers and patients can avoid those errors to improve patient safety and help raise awareness.

In its latest report, ISMP analyzed more than 2,000 events from January 2022 through December 2023.

The number one vaccine error that occurred during that time was patients being given the wrong vaccine. That happened in more than one-quarter of adverse events. Another 20% of errors were due to patients receiving an expired vaccine or a contaminated vaccine. Other errors involved:

• 12% of patients who were given the wrong dose (both overdoses and under-doses),
• 10% of errors occurred because the patient was the wrong age for the vaccine given,
• 9% received an extra dose of the vaccine,
• 7% received the wrong timing on the dose,
• 4% were given a vaccine that was missing an ingredient,
• 2% were given a vaccine via the wrong method, and
• 1% of errors occurred because the vaccine was simply given to the wrong patient.

Nearly half of the errors involved a medical assistant, 46% involved a registered nurse or licensed vocational nurse, and 13% of errors involved pharmacists.

Most of the vaccine errors occurred in outpatient settings, with 43% of errors occurring in medical clinics, 18% in public health vaccine clinics, 17% in doctor’s offices, and 9% in community pharmacies.

ISMP officials said more awareness must be made of the risk in all settings to avoid vaccine errors.

To help reduce vaccine errors, ISMP has issued a number of recommendations. It called for healthcare professionals to verify the identity of the patient, the specific vaccine needed, properly label syringes, document the vaccine, and report errors quickly.

Additionally, ISMP urges healthcare settings to use technology to help prevent errors, identify system-based causes of errors, use multiple-layer risk reduction strategies, and involve patients and caregivers in the vaccine process and error prevention.