Age-Related Vaccine Errors

Since September 2012, the Institute for Safe Medication Practices (ISMP) has been operating the ISMP National Vaccine Errors Reporting Program (ISMP VERP) to collect data about the types of vaccine errors and their underlying causes. Between September 2012 and June 2016, 1754 reports were submitted to the ISMP VERP, most of which came from practitioners working in the outpatient setting, which is where most patients receive vaccines.

Accounting for 20% of all reports, the influenza virus vaccine was the one most often involved in the reported errors. However, there were more errors involving other vaccines in specific settings, based on the typical patient populations served. For example, errors with the hepatitis A vaccine were most commonly reported by staff in public health immunization clinics and errors with herpes zoster and pneumococcal vaccines were frequently reported by staff at community pharmacies.

The most frequently reported vaccine errors included the vaccine itself (23% of all reports), age (20%), dose (12%), extra dose (9%), and wrong interval (7%). The table lists the vaccines usually involved in the errors reported to the ISMP VERP.

Among all vaccine errors submitted to the ISMP VERP, age-related contributing factors were reported most often and were linked to more than 1 in 3 error reports overall (38%). Thirteen percent of these reported errors were due to confusion about the numerous age-dependent vaccines that target the same diseases, particularly those for influenza and hepatitis A and B, as well as combinations that target diphtheria, tetanus, and pertussis and measles, mumps, rubella, and varicella. Another 13% involved a lack of familiarity with the recommended ages for various vaccines or failing to include a step as simple as verifying a patient’s age prior to administration. Similar vaccine abbreviations and labeling or packaging and dense storage conditions played a role in the remaining 12% of age-related vaccine errors.

To prevent age-related vaccine errors, health professionals can make many practice changes, including the following:

• Investigate purchasing age-specific formulations of the same vaccine from different manufacturers to help distinguish them. Whenever brands change, conduct specific training for all staff and ensure electronic and paper order sets are revised.

• Affix auxiliary labels to select vaccines (eg, products with similar names or multiple age-related formulations) to draw attention to key information and help promote correct product selection.

• Verify the patient’s age. Ask the patient or caregiver for a birth date and reference the patient’s health record and/or immunization record. Check immunization registries before ordering and administering vaccines.

• Store vaccines in refrigeration and freezer units large enough for organized and labeled stock. Separate pediatric and adult formulations of vaccines.

• Ask patients or parents to help verify the vaccine prior to administration by reading the vaccine information statement and checking that the patient is within the specific age ranges for the vaccine.

• Employ point-of-care barcode scanning to verify that the correct vaccine and formulation has been selected.

• Build alerts in order-entry systems to warn health professionals if a specific vaccine is prescribed for a patient who is older or younger than the recommended ages for vaccine administration.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.