- Institute for Safe Medication Practices National Vaccine Errors Reporting Program 2022-23 Biannual Report. https://bit.ly/3V6dYmu.
A biannual report on vaccine administration errors voluntarily reported by practitioners shows an upward trend in the years following the COVID-19 pandemic. It also offers risk-reduction strategies to ensure patient safety.
The Institute for Safe Medication Practices National Vaccine Errors Reporting Program (ISMP VERP) received 1,987 voluntary error reports from Jan. 1, 2022, through Dec. 31, 2023. The reports detail the type of error, facility, practice and practitioner involved, plus contributing factors.
While the total is down from the 2,833 reported in 2020-’21, the authors said “the overall trajectory remains higher,” with a spike since the pandemic. ISMP VERP began in 2012, and just 226 vaccination errors were reported in 2019.
The most common type of error in the latest report was the administration of the wrong vaccine (25.2% of reports) followed by expired vaccines (19.8%) and incorrect dosage (12.4%). Other errors included wrong age, extra dose, wrong interval and wrong patient.
Vaccines most frequently cited in error reports were COVID-19 (44.3%), diphtheria, tetanus and/or pertussis (12.7%) hepatitis A and B (9.2%) and influenza (6.4%).
Errors most commonly happened at a family practice (36.7%) or public health (21.8%) facility, while 20% of errors occurred in pediatric practices. Community pharmacies were cited in 8.7% of error reports, which the authors said was “surprising” given the post-COVID uptick in pharmacy vaccinations.
The authors noted, however, that “pharmacists and others face barriers to reporting errors, which include a fear of punishment, no clear definition of what constitutes an error, and lack of time and resources.”
Those barriers speak to the limitations of the report, which relies on volunteered information from practitioners with varying reporting systems and cultures.
The authors suggested dozens of risk-reduction strategies, including staff education and safety efforts, storing vaccines with similar names or abbreviations apart from each other and using prefilled syringes when available.
