March 26, 2015 Volume 20 Issue 6

Recommendations for practitioners to prevent vaccine errorsPart 2: Analysis of ISMP Vaccine Errors Reporting Program (VERP)

While the risk of adverse reactions to vaccines has been given consider-able attention in recent years, the study of adverse events associatedwith vaccine errors has been much less extensive. Despite this, the WorldHealth Organization (WHO) emphasizes that adverse events due to vac-cine errors are more common than adverse events due to the vaccinesthemselves.1,2 Also, the opportunity for vaccine errors is immense—30

or more vaccines will be administered to fully immunize a child in the US by the ageof 6, accounting for a large number of opportunities each year for vaccine-relatederrors to occur during childhood vaccinations alone.1

To collect the details needed to understand vaccine errors and their causes, ISMPpartnered with the California Department of Public Health in September 2012 to de-velop the ISMP National Vaccine Errors Reporting Program (VERP). This is the onlynational vaccine error-reporting program in the US. ISMP sends all reports submittedto VERP to the Vaccine Adverse Event Reporting System (VAERS) used by the USFood and Drug Administration (FDA) and the Centers for Disease Control and Pre-vention (CDC). The primary purpose of the VAERS is to assess adverse events asso-ciated with vaccines. Outside of the error reports received from the ISMP VERP, theVAERS contains a very small number of reports that detail vaccine errors.3,4

In the December 4, 2014 newsletter, we published Part 1 of a 2-year analysis of nearly1,000 reports submitted to the VERP.5 From that analysis, the vaccines most frequentlyreported to be involved in errors included the following, in descending order:

Influenza (IIV3, IIV4, RIV3, ccIIV3, or LAIV4)Diphtheria and tetanus toxoids, acellular pertussis adsorbed, and inactivatedpoliovirus (DTaP-IPV)Hepatitis A (HepA)Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis adsorbed (Tdap)Human papillomavirus, recombinant (4vHPV, 2vHPV)Diphtheria and tetanus toxoids, and acellular pertussis adsorbed (DTaP)Measles, mumps, rubella, and varicella (MMRV)Hepatitis B (HepB)Diphtheria and tetanus toxoids, acellular pertussis adsorbed, inactivated po-liovirus, and Haemophilus influenzae type b conjugate (DTaP-IPV/Hib)Haemophilus influenzae type b conjugate (Hib)

Among all vaccine errors in the 2-year VERP data set, the most common contributingfactors were as follows:

Mistakes in choosing age-specific formulations of vaccines intended to preventthe same diseasesUnfamiliarity with the vaccine, particularly its dose, dosing schedule, age spec-

continued on page 2—Vaccines >

Bloxiverz and Vazculep. A Safety Briefabout potential look-alike confusion be-tween two Eclat Pharmaceuticals products,VAZCULEP (phenylephrine injection) in 50mg/5 mL vials and BLOXIVERZ(neostigmineinjection) in 10 mg/10 mL vials, was publishedin our February 12 issue. Two more reportshave been received, each describing casesin which the wrong drug was prepared. Al-though the 50 mg/5 mL Vazculep vial is apharmacy bulk package meant for phar-macy admixture programs, one error hap-pened in the operating room. Vazculep 50mg/5 mL and 100 mg/10 mL pharmacy bulkpackages should not leave the pharmacy.Fortunately, the recent errors were caughtbefore patients received the wrong drug.

Given the serious consequences of an ac-tual mix-up, ISMP and the American Societyof Health-System Pharmacists (ASHP) dis-tributed an alert through the National AlertNetwork (NAN), which can be viewed at:www.ismp.org/NAN/default.asp. The alerthas also been posted on the National Coor-dinating Council for Medication Error Re-porting and Prevention website, and itsmember organizations have been alerted.

ISMP begins 2015 Annual Fund DriveMedication safety would be very differenttoday without ISMP. The nonprofit organi-zation has worked closely with regulatoryauthorities, standards organizations, profes-sional and industry groups, and you, to im-prove safety. As a result, thousands of prod-uct and practice changes have occurredsince our founding in 1994. We recentlylaunched the 2015 Annual Fund Drive to en-sure that our lifesaving work will continuevia an endowment. Please consider donatingto this year's Annual Fund to help keep ISMPan important part of the fight against pre-ventable medication errors. To contribute,go to: www.ismp.org/support. Thank you!

March 26, 2015 Volume 20 Issue 6 Page 2

ifications, route of administration, and a vaccine’s components (e.g., combina-tion vaccines; diluent and powder)Failure to check or verify the vaccination schedule and the patient’s age, healthrecord, or state immunization information system to avoid invalid doses ad-ministered too soon, or missed opportunities to vaccinateConfusion due to similar vaccine names and abbreviationsConfusion due to similar and ambiguous vaccine labeling and packagingAdministering diluents without vaccines, and/or one component of two-compo-nent vaccinesUsing the wrong vaccine diluentUnsafe storage (e.g., too close to similar-looking vaccines, temperature excur-sions, expired vaccines)Wrong patient errors due to sibling confusion

In Part 2 of this newsletter feature, we provide recommendations to reduce the riskof vaccine errors based on the contributing factors identified in the 2-year data set.The contributing factors are highlighted in red, and the recommendations are listedunder each contributing factor. Some recommendations will reduce the risk of errorsassociated with several different contributing factors. To avoid duplication, theserecommendations appear under a single contributing factor but are highlightedwith an asterisk (*) to note their ability to address other causative factors.

Errors with age-specific formulations

Prior to prescribing, dispensing, or administering a vaccine, verify the patient’sage by asking the birth date (if the patient is available) and referencing the pa-tient’s health record, immunization record, and/or medication administrationrecord (MAR). Also, compare the patient’s current age with information on theapplicable immunization schedule and Vaccine Information Statement (VIS)from the CDC. Affix auxiliary warning labels to vaccines when first received in the pharmacyto draw attention to products with different formulations for neonatal, pediatric,adolescent, and/or adult patients.Investigate purchasing differing age-specific formulations of the same vaccinefrom different manufacturers to help distinguish them.

Wrong patient errors due to confusion between siblings

If multiple children, adults, or an adult and child are being seen at the same timefor vaccinations in the same immediate vicinity, structure the appointment tovaccinate one patient at a time. Moving siblings to separate treatment roomswhen possible is one way to approach the problem.1 If more than one patientremains together, bring only one patient’s vaccines into the treatment area at atime, labeled with the vaccine name and intended patient’s name on each con-tainer. If more than one vaccine must be administered to a patient, keep themseparate (e.g., separate trays; separate vaccine administration stations).* Verify the intended patient’s identity using two unique identifiers (e.g., nameand birth date) before administering each vaccine.

Invalid doses (given too soon) or missed opportunities to vaccinate

Prior to vaccination, verify the patient’s current immunization status by checking

> Vaccines—continued from page 1

continued on page 3—Vaccines >

Outside of baclofen syringe is not sterile.Baclofen injection is used to treat severespasticity associated with multiple sclerosis,cerebral palsy, and spinal cord injuries. It isadministered by the intrathecal route via animplantable pump such as the MedtronicSynchroMed II Programmable Pump orother pumps labeled for intrathecal admin-istration of baclofen. A patient was preppedfor an intrathecal pump insertion usingGABLOFEN(baclofen injection) in a prefilledsyringe. The sterile field was established, aGablofen package with a prefilled baclofensyringe was obtained, and the circulatingnurse opened the package onto the sterilefield, believing it was sterile.

Actually, it is not sterile, although the cartonof baclofen and the peel-off label on the in-ner package are labeled “sterile solutionfor intrathecal use only” (Figure 1). It issealed as if the contents of the packageare sterile. Looking at the label and the waythe syringe is packaged, many would think

the inside contents (syringe holding thedrug) were sterile too. But the syringe issupposed to be used as a refill kit to injectbaclofen through the skin into a port on thepump. It is not for use when implanting thepump, and the risk of contamination due toa nonsterile external surface of the syringeis noted in the package insert.

Although the drug solution and pathway inthe Gablofen prefilled syringes are sterile,the external surface of syringes in allstrengths is nonsterile and has the potentialto contaminate the sterile field. The labelclearly states that the use of a Gablofen pre-

continued on page 3—SAFETY briefs >

Figure 1. The carton and inside tray state “sterilesolution,” which led an OR nurse to believe thesyringe could be placed in the sterile field.

© 2015 ISMP. Reproduction of the newsletter or its content for use outside your facility, including republication of articles/excerpts or posting on a public-access website, is prohibited without written permission from ISMP.

March 26, 2015 Volume 20 Issue 6 Page 3

continued on page 4—SAFETY briefs >

filled syringe in an aseptic setting (e.g., op-erating room [OR]) to fill sterile intrathecalpumps prior to implantation in patients is notrecommended, unless the external surfaceof the prefilled syringe is treated to ensuresterility. Gablofen in vials may be used withconventional aseptic technique to fill in-trathecal pumps prior to implantation. If theprefilled syringe must be used, the packagemust be opened and the medication fromthe syringe dispensed into a properly labeledreceptacle on the sterile field.

The error above was caught by a surgeonwho came to review the back table in theOR. Surgical staff had previously been toldthat the syringe was not sterile, but the cir-culating nurse in the room did not usuallywork with pump implant cases and was notaware of the issue. As a result, the sterilefield was compromised, and all new supplieshad to be opened, including a pump. There’sroom on the labels for wording to help peoplerecognize that the outer part of the syringeis not sterile. The manufacturer, Mallinckrodt,is working to update the labeling and pack-aging of the prefilled syringes. The companyhas also alerted customers that the syringesare not sterile and referred them to a videodescribing proper technique when handlingthe syringe (http://is.gd/UhVrfx).

Left over from a different time. The USPharmacopeial Convention (USP), the Cen-ters for Disease Control and Prevention(CDC), and others recommend placing a be-yond-use date on a multiple-dose vial onceopened. Thus, we have asked Hospira tochange the label on its labetalol multiple-dose vials, which currently prompts usersto document a “date first used” (Figure 1),

cont’d from page 2the patient’s health record and vaccination record to avoid omissions and/orduplicate vaccine doses. If possible, build an alert into the electronic MAR orvaccination record to remind staff to review the patient’s immunization recordor discuss prior immunizations with the patient or parent. Locate missing vaccination records whenever possible by contacting previoushealthcare providers and reviewing state or local immunization informationsystems. If records cannot be located, patients should be started on an age-appropriate vaccination schedule. Post up-to-date, easy-to-read immunization schedules for infants, children,teens, and adults that staff can quickly reference in clinical areas where vacci-nations may be prescribed and administered.6 If possible, link the immunizationschedule to an electronic MAR and/or vaccination record.* Provide parents/caregivers, teens, and adults with easy-to-read immunizationschedules so they know what vaccine(s) they or their child should be receivingduring visits to a healthcare provider.6*If a child or teen misses a particular vaccination(s), create an individualizedcatch-up schedule of immunization and provide it to the parent or caregiver.6*For frequently administered vaccines, establish standard order sets or protocols,which include:7*

The full generic name, brand name (if applicable), and standard abbreviation.8

Criteria for screening patients to determine the need for vaccination, indica-tions, contraindications, and precautions.Directions for administering the vaccine, including the route and any specialprocedures required to enhance safety. Information regarding any required follow-up doses.Details regarding what (e.g., lot number, expiration date) and where (e.g., vac-cination record, immunization registries) to document vaccine administration.An emergency protocol to follow if the patient develops an adverse reaction.

Integrate an ambulatory clinical pharmacist into the healthcare team in pediatricprimary care and public health clinics, and other inpatient and ambulatory settingswhere vaccines are frequently administered. Pharmacists are uniquely positionedto reduce the barriers to appropriate and safe vaccine use. When pharmacistswork directly in patient care areas, significant reductions in vaccine errors, invalidvaccine doses, and missed opportunities to vaccinate have been documented.9*Implement a “universal birth dose policy” to ensure that every newborn receivesthe first dose of HepB vaccine at birth, or no later than at discharge from thehospital.10 Establish a reliable system of informing pediatricians or primary carephysicians about a birth dose of HepB administered (or not) to a newborn.

Wrong route errors caused by unfamiliarity with the vaccine

Post a quick reference for clinicians to verify the route of administration for all vac-cines. An excellent chart is available from the Immunization Action Coalition (IAC).11

Highlight the route of administration on MARs by using boldface type.Highlight the route of administration on vaccine carton labels by circling or us-ing color to bring attention to the information as necessary, or by affixing anauxiliary label to vaccines prone to administration by the wrong route—in-fluenza; rotavirus; measles, mumps, rubella; and varicella vaccines. When possible, purchase vaccines in packaging or containers that are less likelyto mislead clinicians regarding the correct route of administration (e.g., purchaseROTATEQ instead of ROTARIX to avoid accidental injection of the oral vaccine).

> Vaccines—continued from page 2

continued on page 4—Vaccines >

Figure 1. “Date first used” should be changedto “beyond-use date.”

March 26, 2015 Volume 20 Issue 6 Page 4

> Vaccines—continued from page 3

Errors with combination vaccines or vaccines with diluents

On order sets, MARs, and vaccination records, list the brand names and allcomponents of combination vaccines. Only use the vaccine diluents supplied and packaged by the manufacturer withvaccines that require reconstitution. Vaccine diluents are not interchangeable,and stock vials of sterile water or normal saline should not be used as a substitute. Clearly label or distinguish (e.g., circling or highlighting pertinent label infor-mation) diluents if the manufacturer’s label could mislead staff into believingthe diluent is the vaccine itself. Establish a process to keep two-component vaccines together, and to keepdiluents and their corresponding vaccines together if storage requirements donot differ. Dispense the products together in a bag with an auxiliary label to re-mind staff to use both vials. Document the NDC number, lot number, and expiration date of each vial in thevaccination record or log before administration to confirm selection or prepa-ration of both components of two-component vaccines. Documenting actualadministration of the vaccine should always occur after it is given.*Establish ongoing education of clinical staff who might dispense and administervaccines,* which includes discussion of safety issues with two-component vaccinesand vaccines with specific diluents. Staff should understand the differences betweentwo-component vaccines and vaccines packaged with specific diluents.Barcode scanning prior to vaccine administration* could help catch an error ifonly one vial was being inadvertently used and the system required scanningthe barcodes on both vials of two-component vaccines or diluents and corre-sponding vaccines.

Wrong vaccine errors related to vaccine nomenclature

When feasible, circle or highlight with a marker the brand names on carton la-bels of vaccine products that have long generic names, to promote correctproduct recognition.Differentiate the appearance of similar vaccine names on computer screensand MARs by highlighting dissimilarities and including full product names,starting with the brand name (if applicable) first, followed by the generic name,especially for multi-component vaccines (e.g., PENTACEL).* Prescribe vaccines with look-alike generic names using brand names, not bythe CDC-approved abbreviation alone.*If vaccine abbreviations are permitted, allow only current, standard, CDC-ap-proved abbreviations to be used.11 Follow the CDC recommendations to listboth the full generic name (and brand name) along with the approved abbre-viation on all electronic and preprinted forms to reinforce the product identityand the correct use of abbreviations. Use patient vaccination records with enough space to list full vaccine names. Avoid listing the conjugate with polysaccharide vaccines on order entry andautomated dispensing cabinet (ADC) computer screens, pharmacy labels,MARs, vaccination records, and shelf/storage area labels. For example, do notinclude tetanus toxoid when listing the generic name of ActHIB, which appearson the label as Haemophilus b conjugate vaccine (tetanus toxoid conjugate). Prohibit the use of coined or informal names for vaccines. Read back verbal orders to the prescriber for clarification.

continued on page 5—Vaccines >

to a “beyond-use date.” Other manufactur-ers would need to follow suit since the Hos-pira labetalol is the reference drug. Only thebeyond-use date should be used to specifythe date after which an opened multiple-dose vial should not be used. If other multi-ple-dose vials are labeled “date first used,”please notify us.

Avoid mix-ups between hydroxyproges-terone and medroxyprogesterone.A med-ication error was recently reported to ISMPthat involved confusion between hydroxy-progesterone caproate injection (MAK-ENA) and medroxyprogesterone acetateinjectable suspension (DEPO-PROVERA).Makena is used to prevent preterm laborand is often given as an IM injection of 250mg. Depo-Provera is a contraceptive witha dose of 150 mg given IM. It should neverbe given to pregnant women (currentlypregnancy category X). A 400 mg/mL prepa-ration of Depo-Provera is also available foruse as adjunctive therapy and palliativetreatment of inoperable, recurrent, andmetastatic renal or endometrial carcinoma.Given that both medications are commonlyused in obstetrics and gynecology patients,there is a strong possibility of confusingthese medications with one another dueto their look- and sound-alike names, andsimilar dosages and routes of administra-tion.

One way to prevent errors between theseproducts would be to use the brand nameMakena, the only US Food and Drug Ad-ministration (FDA)-approved hydroxyprog-esterone product, when prescribing thedrug. Although medroxyprogesterone isavailable generically, it might be orderedby the brand name, too, with the pharmacistsubstituting a generic product as appro-priate. In the hospital where this error hap-pened, the staff have adjusted their com-puterized prescriber order entry (CPOE)screens to reflect the indication for eachdrug to guide prescribers to the appropriateagent depending on patient circumstances.It’s important to be sure that relevant hos-pital staff are aware of this potential mix-up.

cont’d from page 3

March 26, 2015 Volume 20 Issue 6 Page 5

> Vaccines—continued from page 4

Wrong vaccine and dose errors related to labeling and packaging

In hospitals and birthing centers, separate newborn medications from thosetypically used for mothers in perinatal areas. Whenever possible, administer infant medications in an area that is separatefrom where medications are administered to the mother.* Reduce the risk of look-alike vaccine mix-ups by purchasing vaccine productsfrom different manufacturers so they do not look as similar.* Store vaccines with similar packaging or names on different refrigerator orfreezer shelves to lessen the risk of errors.*Unless the vaccine is prepared in front of the patient and administered imme-diately, vaccines prepared in syringes must be labeled. Peel-off labels to usefor this purpose may be available on some, but not all, manufacturer’s vaccinevials. So it is difficult to standardize a process that includes them. The peel-offlabels can also be used to document administration of a vaccine on vaccinationrecords.*

Errors related to unsafe vaccine storage

Consult the CDC Vaccine Storage and Handling Toolkit to ensure the use ofproper vaccine storage units and equipment, temperature ranges, temperaturemonitoring, placement of vaccines in storage units, and recommended actions.This will help to minimize conditions that could compromise proper handling.12

Purchase refrigeration and freezer units large enough to store and organize la-beled stock. If possible, store vaccines in their own, dedicated refrigeration and freezer units. Separate vials and syringes into bins or other containers according to vaccinetype and formulation. Never store different vaccines in the same containers.Do not store vaccines with similar labels, names, abbreviations, or overlappingcomponents (e.g., DTaP, DT, Tdap, Td) immediately next to each other or on thesame shelf.*Separate the storage areas of pediatric and adult formulations of vaccines,and affix auxiliary labels to the vaccines and/or storage areas to draw attentionto the specific ages for these vaccines.* Label the specific locations where vaccines are stored to facilitate correct, age-specific selection and to remind staff to combine the contents of vials. Examplesof vaccine labels for storage areas are provided by the CDC.13

Do not draw a single vaccine or batches of vaccines into syringes in advance ofimmunization clinics. Draw up vaccines only at the time of administration. As asafer alternative, use commercially available, prefilled and labeled syringes ofvaccines from manufacturers whenever possible.If not using manufacturer’s prefilled syringes in hospitals, the pharmacy shouldprepare each vaccine in a clearly labeled syringe and dispense it for immediateadministration when possible. If vaccines are prepared outside of the pharmacy,each dose should be prepared in a syringe immediately prior to administration.* Although predrawn syringes are discouraged, a limited amount of vaccinemay be drawn into syringes in advance for large immunization clinics if:12

Only one type of vaccine is being administered (or separate vaccine admin-istration stations have been set up for each vaccine). The vaccines are transported at the proper temperatures in the originalpackaging.

continued on page 6—Vaccines >

ISMP webinarsJoin us on April 30 for The Human Dimen-sion: When Being Human Gets in the Wayof Medication Safety. While the importanceof designing reliable systems in healthcareshould not be understated, viewing amishap from the sharp end, at the humancontribution to error, is critical—and inter-esting! During this webinar, a model of thebrain’s information processing system willbe presented, along with the perceptualand cognitive tendencies that influence be-havior, including change bias, inattentionalblindness, normalcy bias, and others. Thefocus of the program will be on the condi-tions, both human and system, that degradehuman performance, and strategies to re-duce their impact on medication safety.

Join us on May 27 for Expanding BarcodeMedication Administration: Making a Dif-ference in the Emergency Department(ED) and Other Outpatient Settings. Despitewidespread adoption of barcode medicationadministration in hospitals, the safety ben-efits of this technology have not been asquickly adopted in many associated outpa-tient clinical locations, such as the ED, on-cology clinics, and dialysis locations, wherea large number of high-alert medicationsare administered. Our distinguished facultywill provide an inside look at the implemen-tation of bedside barcode scanning in clin-ical areas once thought to be “off limits”for this type of technology.

Join us on June 24 for our 2015 Update onThe Joint Commission Medication-RelatedStandards. Learn the most troublesomeMedication Management Standards andNational Patient Safety Goals along withsuccessful approaches taken by healthcareorganizations to accomplish the intent ofthese Standards. A second presenter willprovide personal insight into the Standards,based on a recent Joint Commission surveyat a large, nonprofit, teaching hospital. Thespeaker will share opportunities at both thepharmacy and health-system level.

For details, visit: www.ismp.org/sc?id=349.

March 26, 2015 Volume 20 Issue 6 Page 6

The vaccines are drawn up onsite, not offsite hours ahead of time.Each clinician draws up only 10 doses or fewer from the multiple-dose vial,and each syringe is individually labeled. The vaccines are maintained at proper temperatures that are monitored.Patient flow is monitored to avoid preparation of unneeded doses.Unused doses are discarded at the end of the workday.

Administration of an expired drug

Check for expired vaccines weekly and when vaccines are removed from stock.Rotate the stock based on the expiration date to prevent unnecessary waste byplacing vaccines first to expire in the front.Be aware of the short shelf life of live, attenuated influenza vaccine and imple-ment measures to avoid administering an expired vaccine. Remove expired vaccines from units and storage areas/refrigerators/freezerswhere viable vaccines are stored. Label the vaccines as expired and sequesterthem away from in-date medications and drug preparation areas.If an expired vaccine has been administered in error, revaccination with a validdose is advised.14

Involve the patient in the verification process

Provide all patients, parents, or legal guardians with a VIS in their native lan-guage prior to vaccination. Time to read the VIS before vaccination should beprovided. Document in the patient’s record the publication date of the VIS andthe date it was given to the patient, parent, or guardian.*Link the VIS (in the most predominant languages of the population served) tothe electronic MAR or vaccination record so they are readily accessible.Hold discussions with patients, parents, or legal guardians about the vaccinesbeing administered and answer any questions. The VISs are not a substitutefor direct conversation between the provider and patient regarding the risksand benefits of vaccination.Ask patients or parents to participate in the verification process prior to vaccineadministration by reading the VIS and verifying that the patient is within thespecific ages for the intended vaccine, and by simultaneously comparing thename of the vaccine on the VIS to the vaccine name stated by the clinician andlisted on the vaccine label. Immunization records and/or vaccine logs in whichthe vaccine name, dose, lot number, and expiration date have been recordedimmediately before vaccination can also be verified by the patient or parent asthe information on the vaccine label is read aloud by the clinician.* Remind parents that a fever in young children may occur after vaccination,but the CDC Advisory Committee on Immunization Practices (ACIP) and theAmerican Academy of Pediatrics do not recommend the prophylactic use ofan analgesic/antipyretic medication such as acetaminophen before or at thetime of vaccination.15

References

Bundy DG, Shore AD, Morlock LL, Miller MR.1)Pediatric vaccination errors: application ofthe “5 rights” framework to a national errorreporting database. Vaccine. 2009;27(29):3890-6.Jodar L, Duclos P, Milstien JB, Griffiths E,2)Aguado MT, Clements CJ. Ensuring vaccinesafety in immunization programmes—aWHO perspective. Vaccine. 2001;19(13-14):1594–605.Varricchio F. Medication errors reported to3)the vaccine adverse event reporting system(VAERS). Vaccine. 2002;20(25-26):3049-51.Varricchio F, Reed J, VAERS Working Group.4)Follow-up study of medication errors re-ported to the vaccine adverse event report-ing system (VAERS). South Med J. 2006;99(5):486-9.ISMP. Confusion abounds! 2-year summary5)of the ISMP National Vaccine Errors Report-ing Program (part 1). ISMP MedicationSafety Alert! 2014;19(24):1-6.CDC. Immunization schedules. January 26,6)2015. www.cdc.gov/vaccines/schedules/index.htmlImmunization Action Coalition (IAC). Hand-7)outs: clinical resources. Standing orders foradministering vaccines. January 21, 2015.www.immunize.org/standing-orders/CDC. ACIP abbreviations for vaccines. Febru-8)ary 23, 2015. www.cdc.gov/vaccines/acip/committee/guidance/vac-abbrev.pdfHaas-Gehres A, Sebastian S, Lamberjack K.9)Impact of pharmacist integration in a pedi-atric primary care clinic on vaccination er-rors: a retrospective review. J Am Pharm As-soc (2003). 2014;54(4):415-8.IAC. Hepatitis B: What hospitals need to do10)to protect newborns. July 2013. www.immunize.org/protect-newborns/guide/birth-dose.pdfIAC. Administering vaccines: dose, route,11)site, and needle size. Item #P3085. January2015. www.immunize.org/catg.d/p3085.pdfCDC. Vaccine storage & handling toolkit.12)May 2014. www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdfCDC. Vaccine label examples. February 25,13)2013. www.cdc.gov/vaccines/recs/storage/guide/vaccine-storage-labels.pdfHaber P, Schembri CP, Lewis P, Hibbs B,14)Shimabukuro T. Notes from the field: reportsof expired live attenuated influenza vaccinebeing administered—United States, 2007-2014. Morb Mortal Wkly Rep. 2014;63(35):773.Prymula R, Siegrist CA, Chlibek R, et al. Ef-15)fect of prophylactic paracetamol administra-tion at time of vaccination on febrile reac-tions and antibody responses in children:two open-label, randomised controlled trials.Lancet. 2009;374(9698):1339-50.

> Vaccines—continued from page 5

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