Use Strategies to Avoid Vaccine Mix-Ups

You'll need to stay alert for errors with COVID-19 vaccines...due to boosters, pediatric doses, etc.

Distinguish vaccines in the fridge or freezer by using separate bins, different shelves, or eye-catching labels.

Use cap color as a clue to differentiate unused vials. But ALSO check the vial label...to avoid mix-ups once caps are removed.

Follow a standard process when prepping doses...and always get a double check. For example, the Moderna primary series or additional dose is 0.5 mL, but the booster is 0.25 mL.

Avoid going over the max of 20 punctures currently authorized for each Moderna vial. For instance, note each full dose with a "✔" and boosters with an "X"...to track punctures and calculate waste.

Also be aware, the ORANGE-capped Pfizer-BioNTech vials for kids 5 to 11 are labeled with the manufacture date...NOT an expiration date.

If you immunize or support vaccine clinics, bring only needed vaccines to administration areas...for one patient at a time. Recent errors include patients getting COVID-19 instead of flu vaccine.

When an error occurs, notify your pharmacist ASAP...so they can determine next steps.

Follow your policy for reporting internally. Also help report errors and serious adverse events to VAERS (Vaccine Adverse Event Reporting System)...to alert colleagues nationwide.

Review our technician tutorial, The Basics of Immunization and Vaccines, to brush up on your skills. And bookmark our COVID-19 Vaccines chart to compare authorized ages, doses, storage, etc.

Key References

  • https://www.ismp.org/resources/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines (11-30-21)
  • https://www.cdc.gov/vaccines/hcp/admin/downloads/vaccine-administration-preventing-errors.pdf (11-30-21)
  • https://www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-errors-deviations.pdf (11-30-21)
  • https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html (11-30-21)
Hospital Pharmacy Technician's Letter. December 2021, No. 371210



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