ISMP cautions pharmacists about flu and COVID-19 vaccine mix-ups after cases reported

ISMP has reported multiple mix-ups between the flu vaccine and COVID-19 vaccines since the former became available in September. All the mishaps happened in community and ambulatory care pharmacies, according to ISMP.

“Most of the mix-ups occurred in patients who consented to a flu vaccine but received one of the COVID-19 vaccines instead; however, in two cases, patients received the flu vaccine instead of the intended COVID-19 vaccine,” said ISMP in a news release.

CDC now states that both the flu and COVID-19 vaccines can be administered during the same patient visit without regard to timing.

All of the cases are documented in an ISMP article from October 7.

The article also discusses possible causative factors for the events as well as safe practice recommendations for practitioners (see below). ISMP noted, however, that because most of the errors were reported by consumers, details about the contributing factors were not provided in many cases.

Possible Causative Factors

• Increased demand and coadministration of the vaccines
• Syringes near each other
• Unlabeled syringes
• Distractions
• Staffing shortages

Safe Practice Recommendations

• Provide staffing support.
• Separate vaccination areas.
• Label the syringes.
• Separate the vaccines.
• Identify the patient and requested vaccine.
• Involve the patient/parent in the checking process.
• Document lot number/expiration date.
• Scan the barcode.
• Provide the intended vaccine.
• Report vaccine errors. Report all vaccine errors internally as well as to the FDA Vaccine Adverse Event Reporting System (VAERS), which is mandatory for errors with the COVID-19 vaccines available under an EUA. ISMP also asks providers to report vaccine errors to the ISMP National Vaccine Errors Reporting Program (ISMP VERP).