ISMP updates COVID-19 vaccine errors

The Institute for Safe Medication Practices (ISMP) continues to track the errors that have been reported from the currently authorized COVID-19 vaccines.

With health care practitioners in the United States now administering COVID-19 vaccines for about 4 months now, ISMP said it has analyzed more than 160 COVID-19 vaccine errors voluntarily reported to them between December 14, 2020, and April 15, 2021. In January 2021, they published an analysis of early vaccine errors from the Pfizer and Moderna COVID-19 vaccines.

“In our January analysis, most reports were associated with dilution errors (Pfizer–BioNTech vaccine), wasted vaccine doses, administration to the wrong age group, and errors associated with scheduling second doses,” said ISMP in its new report. “While these error types continue to be reported, we are now receiving a wide variety of different error report types.”

According to ISMP, general error types with all current FDA-authorized COVID-19 vaccines include:

–Administration of a dose lower than authorized.

–Administration to a patient younger than authorized.

–Administration using the wrong injection technique.

ISMP also provides details on error types that are specific to the Pfizer and Moderna 2-dose mRNA vaccines; dilution errors specific to the Pfizer vaccine; and errors specific to Johnson & Johnson’s Janssen vaccine.

See the complete list and all details on ISMP’s site.  

ISMP noted that errors reported to them do not reflect all COVID-19 vaccine errors that might be occurring nationally.

“Because COVID-19 vaccine errors could result in reduced effectiveness, adverse drug events, and other safety implications, we want to share what we have learned about these errors and recommend best practices,” said ISMP.

Loren Bonner, senior editor