ISMP warns about mixing up pediatric and adult COVID-19 shots

With the approval of Pfizer's COVID-19 vaccine for kids as young as 5 years old, the Institute for Safe Medication Practices is warning of the possibility of vaccine providers mixing up pediatric dosages with those meant for people ages 12 and older. 

The Pfizer shot for kids under 12 is one-third the dosage intended for older children and adults. Pfizer is differentiating the two by using different colored caps on vials, but the ISMP said in a Nov. 8 news release that strategy hasn't always worked for previous vaccines. 

The vaccine for kids as young as 5 is supplied with an orange cap and label, while the formulation for older kids and adults has a purple cap and label. But it's unlikely providers would take the vial with them when going to vaccinate someone, as they'd already have it in a prepared syringe, so the label couldn't be verified at the vaccination site. 

Age-related mistakes with other vaccines have been linked to more than a third of vaccine errors reported to the ISMP National Vaccine Errors Reporting Program, the institute said, and it is urging providers to take the following steps to help prevent mix-ups:

  • Create a plan for segregating and storing the different vaccine doses in organized and properly labeled refrigerators and freezers. Store adult and pediatric doses apart from each other.

  • Use barcode scanning wherever possible to verify the correct dosage is being used.

  • Make it a policy to label the individual syringes. Print a label for each patient, or use preprinted labels that differentiate between the two dosages.

  • Only bring the syringe intended for the patient into the vaccination area.

  • Read the syringe's label out loud to a child's parent to confirm the correct dosage is being administered.

  • Document the lot number and date of manufacture prior to administering the vaccine, and document administration afterwards in the patient's profile, on vaccination records and via state or other immunization registries.

  • Report all errors to the FDA and CDC's Vaccine Adverse Event Reporting System.


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