Connie Christian, MBA, CPHRM

Age-Related Error Rates

The Institute for Safe Medication Practices National Vaccine Errors Reporting Program (ISMP-VERP) is calling attention to their 2022 analysis, in which they found that nearly half of vaccine errors (46%), not including COVID vaccines, occurred from age-related errors associated with administering the wrong vaccine or the wrong dose of vaccine.

Error Rates for Age-Related Formulated Vaccines

• Influenza Virus: 31% Error Rate
• Diphtheria, Tetanus, and Acellular Pertussis (DTap): 23% Error Rate
• Hepatitis A and B: 16% Error Rate

The ISMP states that the error rate has not improved significantly during the last decade.

Safe Practice Recommendations from ISMP

Vaccine administration primarily occurs in the outpatient setting, where widespread barcode scanning prior to vaccine administration is often unavailable. ISMP does provide safe practice recommendations to help prevent age-related vaccine errors. Below is a brief overview of ISMP’s recommendations:

• Maximize technology
• Streamline purchases
• Separate vaccine storage
• Verify patient identity
• Label syringes
• Engage the patient
• Document the vaccine(s)
• Educate practitioners

Review of Labeling Strategies

The ISMP has also encouraged the US Food and Drug Administration (FDA) and vaccine manufacturers to review their labeling strategies to reduce the risk of age-related vaccine errors. One recommendation is to prominently display PEDIATRIC or ADULT formulations in different colors at the top of the vaccine cartons, vials, and syringe labels.[1] 

Full Article

For a copy of the ISMP Medication Safety Alert!® with more details and the full list of loss prevention recommendations, visit: www.ismp.org/node/39582.

---

[1] ISMP News release. www.ismp.org/news/ismp-draws-attention-age-related-vaccination-errors