Age-related COVID-19 vaccine mix-ups.

Press Release/Announcement

Age-related COVID-19 vaccine mix-ups.

December 15, 2021

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

Free full text

Related Resources From the Same Author(s)

Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.

April 1, 2015

Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.

July 8, 2015

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

June 13, 2018

Severe hyperglycemia in patients incorrectly using insulin pens at home.

October 25, 2017

Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation.

February 26, 2014

Dangerous wrong-route errors with tranexamic acid.

September 30, 2020

Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically.

February 6, 2013

EPINEPHrine pre-filled syringe shortage.

June 30, 2010

ASHP IV Adult Continuous Infusions.

January 18, 2017

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

May 17, 2021

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.

October 1, 2021

Recommendations for Safe Use of Insulin in Hospitals.

February 8, 2006

Medication Safety Certificate Program.

August 24, 2022

Medication Safety Officer's Handbook.

July 23, 2014

Medication Safety: A Guide for Health Care Facilities.

July 20, 2005

Root Cause Analysis Workbook for Community/Ambulatory Pharmacy.

March 23, 2016

High-Alert Medication Learning Guides for Consumers.

December 5, 2012

The Case for Medication Safety Officers (MSO).

August 22, 2018

ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.

December 5, 2018

ISMP Medication Safety Self Assessment for High-Alert Medications.

October 4, 2017

10 Medication Safety Tips for Hospitalized Patients.

September 25, 2019

Guidance for the Safe Use of Automated Dispensing Cabinets.

May 7, 2019

2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy.

March 6, 2005

Standardize 4 Safety.

May 25, 2016

Patient Safety Resource Center.

August 24, 2005

ISMP's Guidelines for Standard Order Sets.

March 31, 2010

2011 ISMP Medication Safety Self Assessment for Hospitals.

May 4, 2011

ISMP Guidelines for Safe Electronic Communication of Medication Information.

February 6, 2019

ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.

June 7, 2017

Guidelines for Adult IV Push Medications.

February 11, 2015

2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.

May 11, 2017

ISMP QuarterWatch Reports.

January 28, 2009

ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps.

March 4, 2020

Injectable Opioid Shortages: Suggestions for Management and Conservation.

April 25, 2018

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

April 17, 2024

ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications.

March 9, 2011

Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital.

November 26, 2014

Medication safety issue brief. Counterfeit drug prevention and identification.

September 21, 2005

SafeMedication.com.

March 6, 2005

ISMP Long-Term Care Advise-ERR.

July 24, 2013

Eliminating Dangerous Abbreviations, Acronyms and Symbols.

July 6, 2005

ISMP's List of High-Alert Medications in Acute Care Settings.

January 14, 2024

ISMP's List of Confused Drug Names.

July 26, 2023

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

2005 Quest for Quality Prize.

October 5, 2005

Policy Positions and Guidelines.

March 6, 2005

ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology.

May 4, 2022

ISMP Survey on High-Alert Medications in Acute Care Settings.

September 11, 2023

Targeted Medication Safety Best Practices for Hospitals.

February 22, 2024

ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

August 24, 2022

Deep Dive: Racial and Ethnic Disparities in Health and Healthcare.

November 16, 2022

Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed).

March 22, 2023

Medication Reconciliation Handbook, 2nd edition.

September 27, 2006

ISMP Medication Safety Alert!® Nurse-Advise ERR.

March 6, 2005

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

January 26, 2023

Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit.

December 7, 2011

Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals.

September 12, 2018

Health Policy Brief: Improving Quality and Safety.

May 18, 2011

Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report.

May 4, 2016

Leading a Strategic Planning Effort.

March 6, 2005

Use purple bracelets or wristbands only for do not resuscitate status - letter to industry.

August 25, 2021

Consumermedsafety.org

September 8, 2022

ISMP Survey on Drug Shortages.

September 13, 2017

ISMP Follow-up Survey on Smart Pump Data Usage.

March 21, 2018

ISMP Survey on the Common Use of Medication-related Metrics.

May 13, 2015

ISMP Statement on Use of Metric Measurements to Prevent Errors with Oral Liquids.

December 14, 2011

ISMP Survey on IV Push Medication Practices.

August 15, 2018

ISMP Survey on Texting Medical Orders.

July 19, 2017

ISMP Announces 10th Annual Cheers Awards Recipients.

November 21, 2007

How to Prevent Medication Errors.

March 6, 2005

Diversion is a Threat to Patient Safety: Adopting Best Practices.

April 6, 2022 - April 6, 2022

Oral Dosage Forms that Should Not Be Crushed.

December 6, 2006

Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices.

June 4, 2008

Improving Quality of Care and Patient Outcomes During Care Transitions (R01).

January 8, 2020

Looking Collectively at Risk.

March 6, 2005

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

May 6, 2022 - May 6, 2022

Consumer Safe Medicine.

March 6, 2005

Just Bag It.

November 30, 2016

Important change to heparin container labels to clearly state the total drug strength.

December 19, 2012

ISMP Medication Safety Alert. Community/Ambulatory Care Edition.

April 3, 2005

ISMP Medication Safety Alert® Acute Care Edition.

April 3, 2005

Apotex Corp. issues voluntary nationwide recall of Enoxaparin Sodium Injection, USP due to mislabeling of syringe barrel measurement markings.

February 17, 2021

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

February 3, 2021

Medication safety issues with newly authorized PAXLOVID.

January 12, 2022

2012 ISMP International Medication Safety Self Assessment for Oncology.

April 18, 2012

Ways to Improve Electronic Health Record Safety.

September 19, 2018

Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic.

June 30, 2021

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

October 26, 2021 - October 26, 2021

Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization.

March 10, 2021

Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.

February 17, 2021

Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events.

August 15, 2012

Institute for Safe Medication Practices International Mentorship Program.

February 1, 2022 - March 8, 2022

ISMP National Vaccine Errors Reporting Program.

December 18, 2013

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

November 16, 2022

ISMP Medication Safety Self Assessment® for Perioperative Settings.

January 25, 2022

Disrespectful behavior in your workplace.

April 13, 2022

Judy Smetzer Just Culture Champion Scholarships.

August 16, 2023

ISMP Medication Errors Reporting Program.

November 30, 2005

Fellowships and Mentorships Program.

February 8, 2023

ISMP Cheers Awards.

November 20, 2023

Related Resources

Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022.

January 24, 2024

Associations between self-reported healthcare disruption due to COVID-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England.

August 9, 2023

Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content.

November 16, 2022

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

November 16, 2022

Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review.

October 5, 2022

From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect?

July 27, 2022

Clinic design for safety during the pandemic: safety or teamwork, can we only pick one?

May 11, 2022

What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.

May 4, 2022

COVID-19 Focused Inspection Initiative in Healthcare.

March 23, 2022

Patient Safety Primers

COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care

February 23, 2022

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Quality and safety in hospital pediatrics during COVID-19: a national qualitative study.

January 12, 2022

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

October 20, 2021

The less-discussed consequence of healthcare's labor shortage.

October 13, 2021

Dual surgeon operating to improve patient safety.

September 29, 2021

Leadership: an effective human factor during COVID-19.

September 1, 2021

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

September 1, 2021

The COVID trap: pediatric diagnostic errors in a pandemic world.

August 25, 2021

Opioids in the United Kingdom: safety and surveillance during COVID-19.

July 7, 2021

Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic.

June 30, 2021

Missing diagnoses during the COVID-19 pandemic: a year in review.

June 23, 2021

Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.

June 9, 2021

Impact of COVID-19 on inpatient clinical emergencies: a single-center experience.

June 9, 2021

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

June 2, 2021

The calm before the storm: utilizing in situ simulation to evaluate for preparedness of an alternative care hospital during COVID-19 pandemic.

June 2, 2021

Safety events in children's hospitals during the COVID-19 pandemic.

May 26, 2021

Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies.

May 19, 2021

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

See More About The Topic

Health Care Executives and Administrators