Practice Insight: Administering the Correct Vaccine

A Patient Is Given the Wrong Vaccine

A patient complained to the College that they received a COVID-19 vaccine instead of the flu shot they requested.

The pharmacist confirmed that they discussed the patient’s desire for a flu shot, including reviewing the patient’s paperwork. The pharmacist had a conversation with the patient as they prepared the patient’s arm and administered the injection. Only as the pharmacist was filling out the paperwork after the injection did they realize that the wrong vaccine had been administered.

An Error Waiting to Happen

In reviewing the complaint, the panel of the Inquiries, Complaints and Reports Committee (ICRC), noted that the pharmacist had prepared baskets of COVID-19 and flu vaccines earlier in the day. While these baskets were different colours, they were kept side by side in the vaccination area. As a result, the pharmacist inadvertently picked the wrong vaccine while they were in conversation with the patient.

While the panel observed that the harm caused by the error was likely mild, the potential existed for serious consequences. They emphasized that putting the baskets side by side created a significant risk and was an error waiting to happen. The panel was also concerned that the registrant became distracted and did not complete the standard check of ensuring that the vaccine was the right one – demonstrating a lack of attention to detail and due diligence.

However, the panel also acknowledged that the registrant accepted responsibility for the incident and implemented measures to prevent the error from occurring again, including labelling and separating the baskets, and double checking each syringe prior to injecting.

To reflect the severity of the error and potential for serious harm, the panel required the pharmacist to complete a course on preventing and analyzing medication errors and receive an oral caution.

Learnings for Registrants

Learning for registrants. Clearly label syringes in addition to the baskets. Physically separate different vaccines. Always ensure the vaccine is correct prior to administering an injection. Minimize distractions as much as possible. Record medication incidents and good catches (near misses) in the AIMS Program. Communicate appropriately and compassionately with the patient following a medication incident.

There are several key learnings from this case for pharmacists and pharmacy technicians to consider in their own practice when administering injections:

Clearly label syringes in addition to the baskets. Even if prepared doses are sorted into labelled baskets, it is good practice to place labels directly on each syringe as well. Consider using additional methods to differentiate them in a standardized way, such as label colours based on the vaccine, and different basket colours, styles, sizes, etc.
Physically separate different vaccines. Vaccines can look very similar, so to further distinguish them, store vaccines separately. For example, keep different vaccines on separate shelves in the fridge. Only bring the vaccine needed for administration into the vaccination area.
Always ensure the vaccine is correct prior to administering an injection. Pharmacists and pharmacy technicians should always double check that they have selected the correct vaccine for the patient. Before administering the injection, registrants can repeat their screening questions with the patient to help with confirming their choice and understanding. In addition, asking the patient an open-ended question (e.g., “which vaccine are you here to receive today?”) and giving them an opportunity to view the labels for themselves can help with confirming their choice and understanding.
Minimize distractions as much as possible. Focus on one task at a time, avoiding conversation while verifying that the vaccine is correct. It is also a good practice to minimize multitasking between immunizations and patient care activities.
Record medication incidents and good catches (near misses) in the AIMS Program. A thorough root cause analysis should be conducted to identify process improvements to mitigate risks to patient safety and to prevent medication incidents. The incident and findings should be shared with the collective pharmacy team. Read the Pharmacy Connection article The Right Vaccine for the Right Patient.
Communicate appropriately and compassionately with the patient following a medication incident. Ensure that an appropriate pharmacy team member is in contact with the patient to acknowledge and address any concerns. Refer to the Pharmacy Connection article Disclosure of Medication Incidents: A Suggested Framework.