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Errors and Resolutions in the Use of the COVID-19 Vaccine

Jan 19, 2021

As the new vaccines for COVID-19 are rolled out, the Institute for Safe Medication Practices (ISMP) has called attention to some of the missteps in vaccine administration that have occurred, and offers safe practice recommendations to help prevent these errors going forward, including: 

Learning from COVID-19 Vaccine Errors:  


  • Dilution Errors 
  • Vaccine and Monoclonal Antibody Mix-Up 
  • Waste of Vaccine Doses 
  • Administration to the Wrong Age Group 
  • Error with Scheduling the Second Dose 
  • Allergic Reactions 

Avoiding Disasters — Safe Practice Recommendations: 

  • Safely select vaccination sites. 
  • Verify the competency of vaccinators. 
  • Dispense pharmacy-prepared syringes. 
  • Implement an independent doublecheck. 
  • Maximize doses withdrawn from vials. 
  • Identify/differentiate monoclonal antibodies.  
  • Separate vaccine storage. 
  • Plan for the leftover vaccine. 
  • Be prepared for allergic reactions.  
  • Establish scheduling workflow. 
  • Report vaccine errors and adverse reactions. 


To see the full report on COVID-19 vaccine errors and recommendations, visit the Institute for Safe Medicine Practices.


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