System-Based Causes of Vaccine Errors

March 20, 2014
Matthew Grissinger, RPh, FISMP, FASCP

Immunizations are widely recognized as one of the most successful and cost-effective health interventions ever introduced worldwide, preventing between 2 and 3 million deaths per year.

However, errors with vaccines can result in an unintended and unrecognized source of vulnerability. While the immediate impact of a vaccine-related error on a patient may not be serious, such errors may render the vaccine ineffective or reduce its effectiveness, leaving patients unprotected against serious diseases such as hepatitis A, hepatitis B, diphtheria, tetanus, measles, cervical cancer, and many others.

Analysis of reports submitted to the Institute for Safe Medication Practices’ National Vaccine Errors Reporting Program (ISMP VERP) reveals some of the most common contributing factors associated with the reported vaccine errors including:

  • Mistakes in choosing age-dependent formulations of vaccines intended to prevent the same diseases
  • Unfamiliarity with the vaccine, particularly its dose, dosing schedule, age specifications, route of administration, and the vaccine’s various components (e.g., combination vaccines; diluent and powder)
  • Failure to check or verify the patient’s age, health record, or state registry
  • Similar vaccine names and abbreviations
  • Similar and confusing vaccine labeling and packaging
  • Unsafe storage conditions (e.g., stored near other similar vaccines, unwanted temperature fluctuations)
  • Expiration dates not noticed or misunderstood

Does your pharmacy have a role in the oversight of vaccine use in your facility? What types of problems have you seen and what steps have been put into place to prevent errors with the use of vaccines?


Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.