Safety alert issued over age-related COVID-19 vaccine mix-ups

Three pharmacy and medication safety organizations are warning clinicians about a reported increase in age-related COVID-19 vaccine mix-ups.

The Institute for Safe Medication Practice's National Vaccine Errors Reporting Program said it's seen a "steady stream" of mix-ups involving the Pfizer vaccine intended for kids ages 5-11 and formulations for people 12 and older. ISMP said the reports involved hundreds of children and included young children receiving formulations meant for those 12 and up or vice versa.

The safety organization said some errors were linked to vial or syringe mix-ups. In other situations, healthcare providers gave young children a smaller or diluted dose of the formulation meant for people 12 and up.

"Vaccine vials formulated for individuals 12 and up (purple cap) should never be used to prepare doses for the younger age group," the organization said in a Dec. 7 news release shared with Becker's.

ISMP, the American Society of Health-System Pharmacists and the National Coordinating Council for Medication Error Reporting and Prevention issued a National Alert Network warning about the mix-ups to alert providers and share recommendations on how to prevent the errors.

View the full alert here

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