Horsham, Pa.-based Institute for Safe Medication Practices released three main errors being reported regarding the COVID-19 vaccination process.
Since mid-December, the nonprofit has received numerous voluntary reports of errors or hazards related to the administration of COVID-19 vaccines.
Below are the three main categories of errors reported thus far:
1. Dilution errors. Pfizer-BioNTech's vaccine must be diluted with preservative-free sodium chloride injection. Multiple errors have occurred involving too little diluent, which results in administration of too much vaccine and potentially stronger adverse effects.
2. Mix-ups with look-alike products. Moderna's vaccine and the new Regeneron monoclonal antibody have been confused, likely due to labeling issues. Two versions of vial and carton labels for the Regeneron antibody exist, and neither version includes the name of the specific antibody, casirivimab, or has a functioning barcode.
3. Waste of doses. Since both vaccines must be used within six hours at room temperature, some facilities are scrambling at the end of the day to use doses.
ISMP's recommendations include verifying competency of vaccinators, using an independent double-check, planning for leftover vaccines and preparing for allergic reactions.
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