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Analysis of ISMP National Vaccine Errors Reporting Program 2022-2023: Introduction of New Vaccines Correlated with Fresh Mistakes

Vaccine administration errors persist as a concern despite the significant strides in public health through immunization. Our analysis covers 1,987 incidents recorded by the ISMP National Vaccine Errors Reporting Program (ISMP VERP) from January onwards.

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5 min read
Challenges persist in maintaining immunization effectiveness, as success hinges on accurate vaccine...
Challenges persist in maintaining immunization effectiveness, as success hinges on accurate vaccine prescription, distribution, storage, and administration. Our analysis included 1,987 incidents documented in the ISMP National Vaccine Errors Reporting Program (ISMP VERP) from the beginning of the year.

Analysis of ISMP National Vaccine Errors Reporting Program 2022-2023: Introduction of New Vaccines Correlated with Fresh Mistakes

Revamped Rant:

Man, vaccinations are a bloody miracle, but they ain't perfect. A load of shit goes wrong with ’em, from botched prescriptions to expired jabs, and sometimes, it ends up causing more harm than good.

We took a gander at over 1,900 errors reported to the ISMP National Vaccine Errors Reporting Program (ISMP VERP) between January 2022 and December 2023. What'd we find? Most of the reported errors landed on the patients, mainly in outpatient settings where barcode scanning is often MIA. With more and more people getting vaccinated, it's high time we slapped some common sense on these errors to prevent vaccination disasters.

The ISMP has some new safety best practices up its sleeve for hospitals and community pharmacies, and we’ve got the lowdown on the whole shindig. Here's the deal:

Targeted Medication Safety Best Practices

  1. Barcode scanning: Use the bloomin' barcode, you bloody moron! Scan the code on the vaccines and patients before giving them the bloody shot. It's a simple way to ensure you're giving the right jab to the right person, and it's about time these outpatient places started using it.
  2. Standard orders: Get with the program, prescribers! Use the Centers for Disease Control and Prevention’s immunization schedules to guide you to the appropriate vaccine dosage for the patient's age, pregnancy status, and other factors. Don't be a bloody idiot and give ’em something they're allergic to!
  3. Use technology: Pharmacies can benefit from electronic systems like e-prescribing and electronic health records (EHRs). They can help reduce errors and alert you if there's a problem—like if you try to give a kid a vaccine meant for an adult.
  4. Staff training: Make sure everyone who works there knows their shit about vaccines. Regular training sessions can help keep everyone on their toes and following safety protocols.
  5. Double-checking: High-risk vaccines, like those for infants and the elderly, should always be double-checked before administration.
  6. Patient counseling: Explain everything to the patient, and make sure they understand every step of the process. This shit can be scary, so make sure you toss them some knowledge to ease their mind.

Top Types of Vaccine Events

Our analysis showed that the most frequent types of vaccine events reported were as follows:

  • Wrong vaccine: Mixing up vaccines is still a big problem. It happens most often when vaccines look similar—their packages, brand names, or even their abbreviations can be deceiving.
  • Expired vaccine: Y'know how you store your soda in the fridge? Vaccines gotta be kept cold too—and if they're not, they can lose their effectiveness and bacteria can grow in ’em.
  • Wrong dose: Each vaccine has a specific dosage based on factors like age, weight, and the strength of the vaccine. Too much or too little can lead to serious problems.
  • Wrong age: Some vaccines are not suitable for certain ages, like giving an adult a kids’ vaccine or vice versa.
  • Extra dose: Giving an extra dose to a patient isn't just a waste—it can also put ’em at risk of complications.
  • Wrong time: Missing a vaccine appointment or giving a vaccine at the wrong time can reduce the vaccine's effectiveness or expose the patient to risks.
  • Vaccine/component omission: This is when only the diluent (the liquid that keeps the vaccine stable) or a single component of a two-part vaccine is given. It can render the vaccine ineffective.
  • Wrong route: Some vaccines are meant to be injected under the skin, while others need to be given into a muscle. Giving a vaccine the wrong way can make it less effective or even cause harm.
  • Wrong patient: This is a bloody disaster! It happens when a vaccine meant for one patient is given to another. It can expose an innocent person to unnecessary risks.
  • Other: Mistakes like using the wrong diluent or combining vaccines can also happen.

The Hottest New Vaccines

In 2023, the US Food and Drug Administration approved two new vaccines for respiratory syncytial virus (RSV) infection prevention in adults: AREXVY and ABRYSVO. There's also a third one, MRESVIA, expected for 2024/2025. Several new formulas for the coronavirus disease 2019 (COVID-19) and influenza vaccines have also been launched, so make sure you’re up-to-speed on the new kids on the block.

The ongoing issue with wrong vaccine events remains a problem, as evidenced by cases involving these new RSV vaccines. Mixups happen when vaccines have similar names or labels, making it tough to tell them apart.

Remember, the best way to avoid these errors is to implement barcode scanning and follow the ISMP’s new safety best practices for hospitals and community pharmacies. Don't let carelessness and ignorance put lives at risk!

  1. Supporting the use of barcode scanning in outpatient settings can help prevent vaccination errors, ensuring the correct vaccine is administered to the right person.
  2. Standard orders based on Centers for Disease Control and Prevention’s immunization schedules can prevent employees from prescribing vaccines that patients are allergic to.
  3. Technology such as e-prescribing and electronic health records (EHRs) can aid pharmacies in reducing errors and provide alerts for potential problems.
  4. Regular staff training sessions can keep employees updated on the latest safety protocols and best practices.
  5. Double-checking high-risk vaccines before administration can help prevent errors and reduce the risk of complications.
  6. Patient counseling can help reduce anxiety and ensure patients understand the vaccination process.
  7. Most reported vaccine errors involved the administration of the wrong vaccine, often due to similar packaging or brand names.
  8. Expired vaccines can lose their effectiveness and pose a risk due to bacterial growth.
  9. Administering the wrong dose can lead to serious complications.
  10. Giving a vaccine meant for one age group to another can result in ineffective vaccination or potential harm.
  11. Giving an extra dose is a waste and can put the patient at risk of complications.
  12. Missing vaccine appointments or administering vaccines at the wrong time can reduce the vaccine’s effectiveness or expose the patient to risks.
  13. Vaccine omission, only administering the diluent or a single component of a two-part vaccine, can render the vaccine ineffective.
  14. Giving a vaccine the wrong route can make it less effective or cause harm.
  15. Administering a vaccine to the wrong patient can expose an innocent person to unnecessary risks.
  16. Other mistakes such as using the wrong diluent or combining vaccines can also occur.
  17. The US Food and Drug Administration approved two new vaccines for respiratory syncytial virus (RSV) infection prevention in adults in 2023.
  18. Another RSV vaccine, MRESVIA, is expected for 2024/2025.
  19. New formulas for coronavirus disease 2019 (COVID-19) and influenza vaccines have also been launched.
  20. The ongoing issue with wrong vaccine events remains a problem, as evidenced by cases involving new RSV vaccines.
  21. Mixups happen when vaccines have similar names or labels, making it tough to tell them apart.
  22. The ISMP's new safety best practices provide guidelines for hospitals and community pharmacies to improve medication safety.
  23. Implementing these practices can help prevent errors and ensure the safety of vaccines.
  24. News reports on vaccine errors can help raise awareness and promote the importance of safety protocols.
  25. Alerts about potential vaccine errors can help healthcare providers intervene before any harm occurs.
  26. Employees who handle vaccines should be trained in risk management to minimize the chances of errors.
  27. As more people get vaccinated, it’s crucial to review and monitor the safety of the vaccination process.
  28. Systems should be in place to identify and report vaccine errors to prevent future occurrences.
  29. Science and technology play an essential role in developing new vaccines and ensuring their safety.
  30. With the increase in the number of vaccines available, it's essential to focus on the prevention of vaccine errors.
  31. Proper sleep is crucial for workplace-wellness, as it can help reduce stress and improve productivity.
  32. Managing medical conditions, chronic diseases, cancer, and respiratory conditions requires constant care and monitoring.
  33. Digestive health and eye health are important aspects of overall health that should not be overlooked.
  34. Hearing loss can be a concern for those who work in loud environments, and regular check-ups are essential.
  35. Health and wellness, fitness, and exercise can help promote mental health and reduce anxiety and depression.
  36. Aging brings about various changes in the body, and it’s essential to take care of skin, sexual health, and neurological disorders as we age.

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