D

Appendix D

Appendix D-8

07/09/2021 CS 322033-A

A vaccine administration error is any preventable event that may cause or lead to inappropriate medication use or patient harm.1 Vaccine 

administration errors can have many consequences, including inadequate immunological protection, possible injury to the patient, cost, 

inconvenience, and reduced confidence in the health care delivery system. Take preventive actions to avoid vaccine administration errors 

and establish an environment that values reporting and investigating errors as part of risk management and quality improvement.

Vaccine administration errors may be due to causes such as:

1. National Coordinating Council for Medication Error Reporting and Prevention, https://www.nccmerp.org/about-medication-errors

Error(s) Possible Preventive Actions

Wrong vaccine, 

route, site, or 

dosage (amount); 

or improperly 

prepared.

Circle important information on the packaging to emphasize the difference between the vaccines.

Include the brand name with the vaccine abbreviation whenever possible (e.g., PCV13 [Prevnar13]) in 

orders, medical screens, etc.

Separate vaccines into bins or other containers according to type and formulation. Use color-coded 

identification labels on vaccine storage containers.

Store look-alike vaccines in different areas of the storage unit (e.g., pediatric and adult formulations of 

the same vaccine on different shelves in the unit). 

Do not list vaccines with look-alike names sequentially on computer screens, order forms, or medical 

records, if possible.

Consider using "name alert" or "look-alike" stickers on packaging and areas where these vaccines 

are stored.

Consider purchasing products with look-alike packaging from different manufacturers, if possible.

Establish "Do NOT Disturb" or no-interruption areas or times when vaccines are being prepared or 

administered.

Prepare vaccine for one patient at a time. Once prepared, label the syringe with vaccine name.

Do not administer vaccines prepared by someone else.

Triple-check work before administering a vaccine and ask another staff member to check.

Keep reference materials on recommended sites, routes, and needle lengths for each vaccine used in 

your facility in the medication preparation area.

Clearly identify diluents if the manufacturer's label could mislead staff into believing the diluent is the 

vaccine itself.

Integrate vaccine administration training into orientation and other appropriate education 

requirements.

Provide education when new products are added to inventory or recommendations are updated.

Use standing orders, if appropriate.

 Lack of standardized protocols

 Patient misidentification

 Using nonstandard or error-prone abbreviations

 Easily misidentified products 

(e.g. DTaP, DT, Tdap, Td)

If an error occurs, determine how the error occurred and take the appropriate actions to put strategies in place to prevent it from 

happening in the future. The following table outlines common vaccine administration errors and possible preventive actions you 

can take to avoid errors.

 Insufficient staff training

 Distraction

 Changes in recommendations

Vaccine Administration: 

Preventing Vaccine 

Administration Errors
D

Appendix D

Appendix D-9

07/09/2021 CS 322033-A

U.S.Department of 

Health and Human Servic

Centers for Disease

Control and Prevention

Vaccine Administration: Preventing Vaccine Administration Errors

Error(s) Possible Preventive Actions

Wrong patient Verify the patient's identity before administering vaccines.

Educate staff on the importance of avoiding unnecessary distractions or interruptions when staff is 

administering vaccine.

Prepare and administer vaccines to one patient at a time. If more than one patient needs vaccines 

during the same clinical encounter (e.g., parent with two children), assign different providers to each 

patient, if possible. Alternatively, bring only one patient's vaccines into the treatment area at a time, 

labeled with vaccine and patient name.

Documentation 

errors

Do not use error-prone abbreviations to document vaccine administration (e.g., use intranasal route

[NAS] to document the intranasal route—not IN, which is easily confused with IM). 

Use ACIP vaccine abbreviations.

Change the appearance of look-alike names or generic abbreviations on computer screens, if possible.

Improperly stored 

and/or handled 

vaccine administered 

(e.g., expired 

vaccine given)

Integrate vaccine storage and handling training based on manufacturer guidance and/or 

requirements.

Rotate vaccines so those with the earliest expiration dates are in the front of the storage unit. Use 

these first.

Remove expired vaccines/diluents from storage units and areas where viable vaccines are stored.

Isolate vaccines exposed to improper temperatures and contact the state or local immunization 

program and/or the vaccine manufacturer.

Scheduling errors 

(e.g., vaccine 

doses in a series 

administered 

too soon)

Use standing orders, if appropriate.

Create procedures to obtain a complete vaccination history using the immunization information 

system (IIS), previous medical records, and personal vaccination records.

Integrate vaccine administration training, including timing and spacing of vaccines, into orientation 

and other appropriate education requirements.

For children, especially infants, schedule immunization visits after the birthday.

Post current immunization schedules for children and adults that staff can quickly reference in clinical 

areas where vaccinations may be prescribed and administered.

Post reference sheets for timing and spacing in your medication preparation area. CDC has vaccine 

catch-up guidance for DTaP, Tdap, Hib, PCV13, and polio vaccines to assist health care personnel in 

interpreting the catch-up schedule for children.

Counsel parents and patients on how important it is for them to maintain immunization records.

* At this time, COVID-19 vaccination has additional VAERS reporting requirements, including required reporting of vaccine 

 administration errors. Please see https://vaers.hhs.gov/faq.html for more information. 

Adapted with appreciation from Table 11-2, Medication Errors, 2nd ed, by Cohen, Michael. Washington D.C: American Pharmacists Association; 2007.

Healthcare providers are strongly encouraged to report vaccine administration errors to 

Vaccine Adverse Event Reporting System (VAERS).* To file an electronic report, please see the 

VAERS website at https://vaers.hhs.gov/reportevent.html