IMSN Advocacy for vaccine safety

Vaccine related errors may occur at all stages of the medication use process: prescribing, dispensing, preparing, administering, follow-up and planning with a particular emphasis to scheduling and documenting the patient held record (PHR):

  • Wrong patient, especially sibling confusion
  • Wrong time: omissions, too early, delay, extra dose
  • Wrong vaccine: incorrect vaccine administration
  • Wrong preparation: wrong diluent, component omitted in a multicomponent vaccine
  • Wrong dose: incorrect dose (under dose, overdose), extra dose
  • Wrong dosage form
  • Wrong storage: expired vaccine, thermally damaged or deteriorated vaccine
  • Wrong administration technique
  • Wrong route of administration

Many causes of errors and contributing factors are increasing in the context of an increasing number of vaccines, more complex vaccines (combinations of multiple components and valences), ever changing vaccination recommendations and schedules, and vaccine shortages that disrupt immunization plans:

  • Confusion due to unclear brand names; similar names; unclear or similar abbreviations
  • Confusion due to similar and ambiguous packaging: insufficient differentiation among products from one manufacturer, lack of consistency of packaging
  • Confusion due to similar and ambiguous labelling: illegible labels due to small font and label sizes; on curved items such as vials or ampoules, full pieces of information cannot be seen in one view; use of difficult to see colors for text; use of multi-language on packaging; Information placement; multidose not stating the number of doses available nor the volume per dose
  • Confusion between multi-dose and single dose vaccines
  • Age-related contributing factors: age-dependent formulations of the same vaccine; confusion between pediatric and adult formulations; unfamiliarity with dosing and timing of vaccines based on the patient’s age; failure to verify the patient’s age prior to administration
  • Combined or multicomponent vaccines: lack of identification and use of the appropriate diluent; misunderstanding of the reconstitution of a vial with a prefilled syringe; giving just one component instead of the intended combination vaccine; use of an unintended diluent instead of the specific diluent
  • Complex vaccination schedules and frequently changing vaccination recommendations
  • Vaccine shortages leading to the use of different combined vaccines than intended and modification of the vaccination schedules
  • Storage conditions: temperature lower or higher than recommended; products stored near each other (not only vaccines, but also neuromuscular blocking agents, insulin, etc.); unclear expression of expiry date; water damage (from freeze packs) degrading labels
  • Overcrowded leaflets: hidden information related to the validity of reconstituted vaccines

In 2015, considering that greater worldwide attention to the problem of unsafe design of vaccine packaging and labelling was needed, the International Medication Safety Network (IMSN) prepared recommendations on the basis of the work previously done by members, especially the ISMP. The IMSN Position Statement on Safer Design of Vaccines Packaging and Labelling called on healthcare professionals, pharmaceutical companies, technology vendors, professional organizations, and regulatory/standard-setting organizations to help improve vaccine safety and efficacy. Read on…

In 2020, the International Medication Safety Network (IMSN) released its fourth Global Targeted Medication Safety Best Practices aimed at preventing errors related to improper preparation of 2-component vaccines. Read on…

In 2021, the International Medication Safety Network (IMSN) launchs its Covid-19 Vaccine Safety initiative by inviting key stakeholders to participate to of the IMSN COVID-19 Vaccine Safety Interest Group. Read on…