Uptick in vaccine-related incidents


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Heads-up to pharmacists after errors see COVID-19 AstraZeneca vaccinations inadvertently administered to people expecting Pfizer or flu shots, or to underage patients

Community pharmacists have been reminded of their responsibilities after incidents have occurred relating to administration of COVID-19 vaccines.

PDL’s Professional Officers, who man the phone lines providing advice to pharmacists on risk minimisation, have reported some issues—emphasising that community pharmacy needs to run a tight ship when it comes to vaccination.

“We have noticed an uptick in vaccine-related incidents, which is to be expected as pharmacists are heavily involved in the roll out,” PDL Professional Officer Georgina Woods told AJP.

She said the most common incidents included vaccinating a patient aged under 18, vaccinating outside of the suggested timeframes and drawing up errors with multi-dose vials.

PDL encourages pharmacists to check each patient’s date of birth carefully, as the minimum age for Vaxzevria administered in community pharmacies in most jurisdictions is 18 years.

Pharmacists are also encouraged to ensure that they have the correct volume when drawing up the vaccine. An example of an error that has been reported is 0.05mL instead of the 0.5mL required.

PDL has also heard reports of people being inadvertently administered the Vaxzevria (AstraZeneca) vaccine expecting a different vaccine.

For example, one person was expecting an influenza vaccine and received a COVID-19 vaccine.

“That’s a concern,” said Ms Woods. She added that while pharmacies have recently been quite focused on COVID-19 vaccines, it’s important to note that influenza vaccinations are still ongoing.

Some patients have also received Vaxzevria when they were expecting Pfizer’s Comirnaty vaccine.

“The general public are a little confused with the mixed messaging and sometimes there is expectation of the Pfizer vaccine because they’re not aware that it’s not currently available in pharmacies,” she said.

“As Moderna rolls out we know that that’s another vaccine on the market that we may be administering, so it’s very important to communicate – with open-ended questions – which vaccine the person is expecting.”

Ms Woods said the majority of incidents can be avoided by excellent and consistent process.

“Check the AIR prior to vaccinating, not afterwards. This is imperative and present in the vaccination standards in some states,” she urged.

“This is a simple risk management strategy that can avoid errors such as vaccinating too early, providing the vaccination to a patient that is underage or providing the incorrect vaccination.”

“Patients are very stressed and confused so they are not always a reliable source of information. Use tools such as the AIR and MHR to assist you with the risk assessment prior to vaccination.

“I acknowledge that the remuneration is very disappointing however workarounds or shortcuts can potentially result in critical incidents. Treat your patients as you would wish you or your family to be treated – take the time to allow them to be fully informed, respect the consent process and answer their questions.

“PDL are really proud of our members for participating in the vaccine roll out, especially as they are already overworked and stressed due to the pandemic,” added Ms Woods.

“We know of many members choosing to spend time at work vaccinating or running the business rather than being with their family on the weekends.

“A great example of this is Curtis Ruhnau (PDL NSW Chair) who spent last weekend vaccinating as there was increased demand in his LGA in response to the state government announcements and the death of a community member,” she said.

“We don’t want our members to think we’re being critical because we expect errors when we’ve got large volumes of things happening, but there are errors that are happening and nearly all of them can be avoided if you have that consistent process.

“Think about simple strategies that might help – a sticky note with the DOB of an 18-year-old on that day might be useful – think of yourself as a bouncer at the door of a nightclub! Or perhaps a note with the date in four weeks’ time, to assist you with determining if a vaccine is too early—whatever it takes for your team to avoid incident.

“Importantly, keep up to date with the legislation, guidelines and standards. These are changing rapidly and all vaccinating pharmacists are required to know exactly what is expected of them.”

While the reports are currently internal, with PDL gathering its data, Ms Woods said “it does take time for complaints to come through, so we expect there will be some that escalate.

“It can be very confronting to make an error and everything is very emotionally loaded at the moment.

“If you make a mistake – stay calm, contact PDL, we can then tell you which steps to take thereon in.”

See PDL’s top tips for pharmacists to avoid vaccination errors here

For immediate advice and incident support, PDL Professional Officers are available on 1300 854 838, 24/7 Australia-wide.

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