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In 2021, COVID-19 vaccine errors were among the top medication safety issues voluntarily reported to the Institute for Safe Medication Practices (ISMP), the group reported.

From Dec. 14, 2020, through April 15, 2021, the most common error associated with FDA-authorized coronavirus vaccines was administration of the wrong dose -- usually related to syringe malfunction or leakage, dose measurement mistakes, or administration of air in an empty syringe, according to Matthew Grissinger, BSPharm, director of Error Reporting Programs at ISMP.

Another common issue was vaccination of people not technically eligible due to age at the time: under 16 years for the Pfizer-BioNTech vaccine and under 18 years for the Moderna and Johnson & Johnson vaccines.

Many of these issues still apply today, along with new challenges, Grissinger told the audience at the American Society of Health-System Pharmacists (ASHP) Midyear .

"The new concern as of today is the mix-up of flu and COVID vaccines, because CDC recommends you get the flu shot and the booster, both at the same time," he noted, citing 20 reports in the past month of this kind of mistake. Anecdotally, he has also heard of a mix-up between epinephrine and a COVID vaccine, he added.

To prevent errors with these vaccines, Grissinger urged providers to dispense pharmacy prepared and labeled syringes when possible and to take care to differentiate monoclonal antibodies from vaccines.

Another common pharmacy problem reported to ISMP was stocking errors on the automated dispensing cabinet (ADC). This could arise from the time-saving practice of scanning one tablet multiple times when multiple tablets are used, or when intact medications are returned to the ADC without scanning the medication's barcode.

ISMP's response to vaccine and tablet errors was to make barcode verification a new medication safety best practice for hospitals in 2022-2023.

Updated every 2 years, the draw attention to safety issues that continue to cause fatal and harmful medication errors despite repeated warnings. Problems are drawn from ISMP's National Medication Errors Reporting Program, its National Vaccine Errors Reporting Program, and cases from literature, media reports, and the ECRI Institute (an ISMP affiliate).

Although the 2022-2023 best practices probably won't be published until early 2022, Christina Michalek, RPh, a medication safety specialist and administrative coordinator of ISMP, offered a preview at the ASHP session.

A new ISMP best practice is to "maximize the use of barcode verification prior to medication and vaccine administration by expanding use beyond inpatient care areas" to emergency departments, infusion clinics, dialysis centers, radiology, cath labs, and outpatient areas, according to Michalek.

In another new best practice, providers are also urged to "safeguard against errors with oxytocin use." For example, orders for oxytocin infusions should be standardized by dose, concentration, and rates; and infusion bags should be labeled on both sides to avoid confusing them with plain hydrating solutions and magnesium infusions, Michalek said.

Finally, she noted the upcoming directive to "layer numerous strategies throughout the medication use process to improve safety with high-alert medications" such as chemotherapy, opioid infusions, IV insulin, and heparin infusions.

This would entail addressing system vulnerabilities in each stage of the medication use process, ideally going beyond storage labeling and provider education to strategies that may be harder to implement but are more effective at preventing mistakes (e.g., automation, physical barriers).