HORSHAM, PA—Since the 2021-2022 influenza (flu) vaccine became available in September, the Institute for Safe Medication Practices (ISMP) has received multiple reports of mix-ups. Some patients have consented to a flu vaccine but received one of the COVID-19 vaccines instead, while others have received the flu vaccine instead of the intended COVID vaccine.

Causative factors may include increased demand and co-administration of the vaccines. The Centers for Disease Control and Prevention (CDC) has stated that both the flu and COVID vaccines can be administered during the same visit and encouraged providers to offer both to increase the probability that patients will become fully vaccinated. In addition, the U.S. Food and Drug Administration (FDA) has recommended a third COVID vaccine dose for eligible immunocompromised patients and approved a Pfizer-BioNTech COVID vaccine booster.

The October 7, 2021 issue of the ISMP Medication Safety Alert!^® Acute Care newsletter details several cases reported by healthcare consumers who received the wrong vaccine and outlines other possible causative factors, including syringes for different vaccines being stored next to each other, unlabeled vaccine syringes, distractions during administration in busy pharmacies, and staffing shortages.

ISMP recommends several safety strategies for healthcare organizations to avoid mix-ups during the vaccination process. Providing adequate staffing support and scheduling vaccinations for a dedicated block of time each day where practitioners are not also dispensing regular medications can help reduce the chance of errors. Other recommendations include using barcode scanning during vaccine preparation and labeling, using manufacturer prefilled syringes of flu vaccine, and involving the patient in the checking process to verify which vaccine they are receiving.

It is mandatory to report errors with COVID-19 vaccines available under Emergency Use Authorization (EUA) to the CDC and FDA’s Vaccine Adverse Event Reporting System (VAERS). ISMP also asks providers to report vaccine errors to the ISMP National Vaccine Errors Reporting Program (VERP). For a copy of the full ISMP newsletter article with case descriptions and recommendations, click here.

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 25 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. Visit www.ismp.org and follow @ismp_org to learn more.

For more information, contact:
Laurie Menyo, Director of Strategic Communications
610.825.6000 ext. 5310
lmenyo@ecri.org

Renee Brehio, ISMP Public and Media Relations
614.376.0212
rbrehio@ismp.org