RM Alert: COVID-19 Vaccine Errors and Deviations

Case study: A patient presents to the pharmacy for a COVID-19 vaccine. During the intake process, the pharmacist mistakenly pulls the Moderna vaccine for a 16-year-old patient. The error is discovered during the documentation process after the injection was given. What should the pharmacist do?

The CDC has an excellent resource for those providing COVID-19 immunizations regardless of which vaccine was being administered when an error occurs. The full chart is listed at https://www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-errors-deviations.pdf.

The chart contains resources to prevent and report administration errors and actions to take after an error has occurred. Since each of the three currently approved vaccines have different doses, dosing intervals, and approved age groups, the chart provides guidance on those deviances from the CDC guidelines. This can be helpful when the wrong dose is inadvertently drawn up and given or the wrong vaccine is administered as a second dose.

For all vaccine administration errors:

  1. Inform the recipient of the vaccine administration error.
  2. Consult with the state immunization program and/or immunization information system (IIS) to determine how the dose should be entered into the IIS, both as an administered dose and to account for inventory.
  3. Providers are required to report all COVID-19 vaccine administration errors—even those not associated with an adverse event—to VAERS.
  4. Determine how the error occurred and implement strategies to prevent it from happening again.

For specific errors such as the case study above, refer to the CDC website for specific directions. It is also important to notify the claims department at Pharmacists Mutual of any such errors in case the patient develops injuries in the future that might relate back to the vaccination error.