Report: 82.3% of Reported Vaccine Errors Reached the Patient

In the Institute for Safe Medication Practices (ISMP) National Vaccine Errors Reporting Program (VERP), investigators reported that the majority of reported errors (82.3%) reached the patient, with the most reported errors including administering the wrong vaccine (25.2%) and administering an expired vaccine (19.8%). According to ISMP, errors can occur at any stage of vaccination, including scheduling, ordering, dispensing, preparation, and administration of vaccination. This can result in inadequate protection, increased cost, injury, and reduced confidence in vaccines.

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In the report, investigators accessed the ISMP VERP database for events reported to ISMP from January 1, 2022, through December 31, 2023. There were 1987 errors included as well as demographics, event type, contributing factors, type of facility, type of practice, and practitioner type in each report.

The investigators found that there was a slight reduction in errors that reached the patient, decreasing from 87.8% in 2017-2018 to 82.3% in 2022-2023. Approximately 88.2% of the reports came from community settings, which included medical clinics, physician practices, ambulatory hospital, community pharmacy, and public health immunizations. The majority of errors were reported with COVID-19 vaccines (44.3%), followed by diphtheria, tetanus, and/or pertussis (12.7%), hepatitis A and B (9.2%), influenza (6.4%), and meningococcal vaccines (5.1%). Additionally, the results showed that errors also occurred with vaccines to treat emerging diseases, such as smallpox and monkeypox, which resulted in 6.8% of errors.

The most frequently reported practitioners involved with reported events were medical assistants, registered nurses, and licensed vocational nurses/licensed practical nurses, and the most reported settings were medical clinics, public health immunization clinics, and physician practices, according to the report. For providers, 36.7% were reported from family practices and 21.8% were reported from public health setting. There was an increase in reports from public health providers in 2017 to 2018 (13.4%) as well as pharmacy providers in 2017 to 2018, increasing from 4.6% to 11% in 2022 to 2023.

In the family practice setting, the COVID-19 vaccine and hepatitis B vaccines were most frequently reported with errors at 37% and 5.4%. In public health clinics, the most frequently reported errors were COVID-19 vaccines at 47% and smallpox and mpox at 7.2%.

Administration of the wrong vaccine, an expired vaccine, and “event type not listed” accounted for 55% of reported events. For event type not listed, the reporters were prompted to specify the event type. Of 199 events, 28.1% were associated with contamination, deterioration, or an expired vaccine, and 19.6% were associated with device malfunction or patient movement

For administration of the wrong vaccine, contributing factors like similar packaging, names, abbreviations, and storage errors resulted in 79.6% of events, with the majority of abbreviation/naming convention errors being for COVID-19 vaccines (17.2%) and diphtheria- and tetanus-containing vaccines (21.6%). For expired vaccines, the contributing factors included ambiguous or confusing expiration dates (51.9%) and a lack of routine checks for expired products (44.7%). Most of the reports were for COVID-19 vaccines (71%) followed by haemophilus influenzae type b and hepatitis A vaccines at 3.8% and 3.1%, respectively

Other vaccination errors included wrong age, extra dose, and wrong timing/interval. For wrong age, 9.8% of the reports submitted included the wrong age for the product received, with 34.5% being for COVID-19 vaccines, followed by diphtheria, tetanus, and/or pertussis vaccines. Extra doses accounted for 8.5% of all vaccine errors, with 49.1% of reports including failure to check patient’s chart or vaccine registry before administration. Furthermore, 14.2% were related to coadministration of 2 products.

Lastly, 7.4% of vaccine errors were due to wrong vaccine interval, and 49.1% were due to failure to check the patient’s chart of vaccine registry prior to vaccination. Additionally, 16.3% of errors of wrong vaccine interval included a lack of familiarity with vaccination interval for product. Of reports due to a failure to check vaccination status included COVID-19 vaccines (70.8%) and hepatitis A or B vaccines (29.2%).

REFERENCE

Institute for Safe Medication Practices. ISMP National Vaccine Errors Reporting Program 2022-2023 Biannual Report. October 2024. Accessed October 29, 2024. https://online.ecri.org/hubfs/ISMP/Resources/ISMP_Vaccine_Report.pdf