Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Publication Type: Safety Bulletin
Single or Multiple Incident: Multiple
Date: 2/25/2021 12:00:00 AM
Country: Canada
This Safety Bulletin shares a number of leading practices that facilitate the safe administration of a COVID-19 vaccine. These practices, which incorporate learning from past vaccine errors, will evolve over time, as additional knowledge is gained and new guidance is developed. Information presented is valid at the time of publication. Vaccine errors reported with the COVID-19 vaccine as well as errors with other vaccines were reviewed. Errors and the risk for errors for each of the following categories is provided: storage, preparation, administration, and documentation. Strategies for safe vaccine practices relative to each of these categories are provided.

Additional Details

Device:
multidose vial, needle, syringe, refrigerator, freezer, ultra-low freezer
Medication/Gas/Fluid:
vaccine, COVID-19 vaccine (Moderna, Pfizer-BioNTech), shingles vaccine, insulin, neuromuscular blocker
Medication/IV List:
neuromuscular blocking agents, insulin, subcutaneous and IV

Communication
  1. Suggest that patients wear short-sleeved or sleeveless clothing to their vaccine appointments.
  2. Provide patients with documentation of vaccination, including product name, lot number, and date of vaccination. MyMedRec and CanImmunize apps are options to store this information (including pictures).
Rules / Policies / Procedures
  1. Follow the manufacturer’s storage instructions and public health guidelines for temperature monitoring, and develop a preparedness plan for temperature excursions.
  2. Never store different vaccines or drug products in one container and clearly separate and label products; consider a dedicated refrigerator/freezer.
  3. Wherever possible, use bar-coding technology for product identification.
  4. Consider bundling any required diluent together with the vaccine (e.g., upon removal of the vaccine from the freezer).
  5. Regularly review refrigerated/frozen vaccines, and remove any expired product.
  6. Develop and follow a standard process, supported by a real-time, quick-reference sheet for dose preparation of each vaccine product.
  7. Label all prefilled syringes with the product name, dose (volume), lot number, and beyond-use date and time.
  8. Label all vaccine vials with both the puncture and beyond-use date and time.
  9. Use a checklist to identify vaccine contraindications or precautions.
  10. Use appropriate landmarking to avoid injection complications.
  11. During the first vaccine appointment, book the patient’s second appointment (at an appropriate interval), if possible. Send appointment reminders by phone, text, or email.
  12. The person administering the vaccine should be alert to visual cues indicating a potential undetected error from a previous step (e.g., appearance of syringe contents differing from expectations, incorrect volume).
  13. Review of a labelled syringe prior to administration supports the identification of a potential error.
  14. If possible, the timing of future inoculations with a COVID-19 and other planned vaccines needs to be considered.

Preventing Errors with COVID-19 Vaccines: Learning from Vaccine Incidents