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Publication Type: Safety Notice
Single or Multiple Incident: Multiple
Date: 9/17/2021 12:00:00 AM
Country: Australia

This safety notice addresses the correct preparation and administration of the Pfizer COVID-19 vaccine. The Pfizer COVID-19 vaccine (Comirnaty®) is presented in a multi-dose vial which requires dilution with sodium chloride 0.9% injection prior to drawing up and administration. There have been incidents reported where a previously used COVID-19 Pfizer (Comirnaty®) vaccine vial was inadvertently diluted a second time. This resulted in six ultra-low doses of vaccine that were then administered to patients. Several contributing factors are provided including the issue of used and unused vaccine vials present together in the vaccine preparation area. The alert provides recommendations to prevent dosing errors.

Additional Details

Medication/Gas/Fluid:
vaccine, COVID-19 vaccine, Pfizer COVID-19 vaccine (Comirnaty®), normal saline, 0.9% sodium chloride injection


Preparation of Pfizer COVID-19 vaccines