In which of the following positions should a medical assistant place an 18 month old patient when administering?

Medication errors can occur at any time between when a clinician prescribes a medication and a patient receives the drug. If the patient is fortunate, a medication error will have little to no effect on their wellbeing. But if the patient is less fortunate, a medication error can lead to significant harm, even death. As the data shows, this happens much more than it should.

The U.S. Food and Drug Administration states that it receives more than 100,000 U.S. reports annually associated with a suspected medication error. Furthermore, it was estimated that medication errors harm an estimated 1.5 million people annually. Every one of these people has a story to be told about an error that could have been avoided.

Here are six stories about medication errors that received increased media attention.

1. Vecuronium injected instead of Versed

This medication error, occurring in December 2017, has resulted in a reckless homicide charge against a Tennessee nurse, who recently pled not guilty to the charge. As the Associated Press and other news outlets reported, the nurse allegedly injected a 75-year-old patient with the paralytic anesthetic vecuronium instead of Versed, a sedative. The nurse supposedly chose to override safeguards when she could not find Versed in an automatic dispensing cabinet, typed "VE" into the cabinet's system, and then selected the first medication — vecuronium — that came up on the list.

2. Pegfilgtastim administered instead of filgrastim

This medication error took the life of an Air Force veteran and resulted in an $800,000 federal government settlement, according to a report in The State. In early 2017, the patient reportedly went to Dorn VA Medical Center in South Carolina with nausea and vomiting. He was administered doses of pegfilgtastim but should have received filgrastim.

While both medications are administered by syringe and intended to stimulate white blood cell growth, the prescribed filgrastim can be taken daily. Following 11 days at the hospital and multiple doses of pegfilgtastim, the patient died after developing pulmonary toxicity leading to severe acute lung injury.

3. Excessive amounts of Levophed administered

This 2014 medication error at Vibra Hospital of Sacramento (Calif.), a long-term, acute-care facility, claimed a patient's life. The California Department of Public Health (CDPH) also penalized the facility a maximum fine of $75,000.

As The Sacramento Bee reports, referencing a CDPH regulator report, the patient's heart stopped following administration of Levophed, a blood pressure drug. While the medication type was correct, a nurse administered 3,000-8,000 times the prescribed dosage. Numerous factors contributed to this error, regulators determined, including the lack of safeguards for high-alert medications, administering nurse's lack of experience with Levophed, and failure for a second nurse to sign off on dispensing the medication.

4. Tryptophan prescribed instead of baclofen

This medication error cost the life of a Canadian child. According to a report from the ISMP Canada Safety Bulletin, the child had been receiving a prescribed dose of tryptophan at bedtime to treat a sleep disorder for about 18 months. A refill was ordered and filled. The child received the prescribed dose but was found dead in his bed the next day. The post-mortem toxicology test identified the antispasticity agent baclofen at the expected concentration of the prescribed tryptophan. It was determined that the child had received a dose of baclofen more than 20 times the maximum recommended pediatric dose. As ISMP notes, "This finding was consistent with a selection error having been made at the pharmacy, whereby one ingredient was inadvertently substituted for another."

The error and child's death has prompted his mother to push for mandatory reporting of all errors made by Ontario pharmacies.

5. Order for warfarin misplaced

A transcription mistake was the cause of this 2015 medication error that eventually led to the death of a nursing home resident. As McKnight's Long-Term Care News reports, citing information from a Minnesota Department of Health report, a resident at Golden Living with a history of stroke and atrial fibrillation was on long-term therapy with warfarin. A nurse transcribing the resident's warfarin order placed the order in another resident's record. The error went unnoticed. For nine days the resident who should have received the warfarin did not. This resident was hospitalized and later died of a stroke and respiratory failure.

As the McKnight's report notes, the news of the medication error and death came just over a month after a report of another error at a nursing home that led to a resident's death. The cause: administration of 10 times the resident's normal dose of morphine.

6. Navane dispensed instead of Norvasc

While this medication error affecting a 71-year-old patient didn't make many news headlines, it did become the subject of a 2016 Journal of Community Hospital Internal Medicine Perspectives article. An outpatient pharmacy accidentally dispensed the antipsychotic thiothixene (Navane) instead of the prescribed anti-hypertensive medication amlodipine (Norvasc). The patient took the wrong medication for three months, leading to physical and psychological harm. "Despite the many opportunities for intervention, multiple healthcare providers overlooked her symptoms," the authors noted.

formerly Immunization Action Coalition (IAC) Sign up for email newsletter IAC Home | Ask the Experts | Administering Vaccines Administering Vaccines General Issues Vaccine Administration Errors General Issues   Note: Specific information about the administration of most vaccines is included in the Ask The Experts set for that vaccine. For additional questions and answers about routine vaccination during the COVID-19 pandemic, please see the COVID-19 and Routine Vaccination section of Ask the Experts, www.immunize.org/askexperts/experts_covid19.asp. For questions and answers about COVID-19 vaccination, please see the COVID-19 vaccine section of Ask the Experts, www.immunize.org/askexperts/experts_cov.asp. I was recently told by a colleague that pregnant healthcare personnel were not to administer live vaccines to others. I had never heard that in school or practice. Is that true? This is not true. Pregnant healthcare personnel may administer any vaccine except smallpox vaccine. Is it acceptable to administer vaccines in the nurses' station where vital signs and other patient care is performed? Yes. Vaccines can be administered in a patient care area. The recommendation from CDC's safe injection practices experts is that storing and preparing vaccines should not be done in the same area where patient care is conducted. These activities should be done in a separate area. What is the appropriate anatomic site and needle length for intramuscular and subcutaneous vaccine injection? Appropriate site and needle length depends on age, route of injection, and body mass. Most injected vaccines are administered by the intramuscular route. Please refer for details to the IAC handouts on administering intramuscular and subcutaneous vaccines to children and adults at www.immunize.org/catg.d/p2020.pdf and to adults only at www.immunize.org/catg.d/p2020a.pdf. A summary of needle length and site selection by age is below. For intramuscular injections (use a 22- to 25-gauge needle for all ages): • For neonates (first 28 days of life) and preterm infants the anterolateral thigh should be used. A ⅝-inch needle usually is adequate to penetrate the thigh muscle if the skin is stretched flat between the thumb and forefinger and the needle is inserted at a 90-degree angle to the skin. • The anterolateral thigh is preferred for infants younger than age 12 months. For the majority of infants a 1-inch needle is sufficient. • For toddlers age 12 months through 2 years the anterolateral thigh muscle is preferred. The needle should be at least 1 inch long. The deltoid muscle can be used if the muscle mass is adequate. • For children age 3 through 10 years, the deltoid muscle is preferred; the needle length for deltoid site injections can range from ⅝ to 1 inch on the basis of technique. The anterolateral thigh can also be used. In this case the needle length should be 1 inch to 1.25 inches. • For adolescents 11 through 18 years, the deltoid muscle is preferred. The anterolateral thigh can also be used. For injection into the anterolateral thigh, most adolescents will require a 1-1.5-inch needle. • For adults age 19 years and older, the deltoid muscle is preferred. The anterolateral thigh also can be used. � For men and women who weigh less than 130 pounds (less than 60 kg), a ⅝-inch needle is sufficient to ensure intramuscular injection in the deltoid muscle if the injection is made at a 90-degree angle and the tissue is not bunched. � For men and women who weigh 130–152 pounds (60–70 kg), a 1-inch needle is sufficient. � For women who weigh 152–200 pounds (70–90 kg) and men who weigh 152–260 pounds (70–118 kg), a 1- to 1�-inch needle is recommended. � For women who weigh more than 200 pounds (more than 90 kg) or men who weigh more than 260 pounds (more than 118 kg), a 1�-inch needle is recommended. For subcutaneous injections (use a 23- to 25-gauge needle for all ages): Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for infants younger than age 12 months and in the upper-outer triceps area of people age 12 months and older. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. A ⅝-inch needle length should be used for all ages. More information on injection technique is in the ACIP General Best Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.   Why are some vaccinations given subcutaneously (SC) while others must be given intramuscularly (IM)? In general, vaccines containing adjuvants (a component that enhances the antigenic response) are administered IM to avoid irritation, induration, skin discoloration, inflammation, and granuloma formation if injected into subcutaneous tissue. This includes most of the inactivated vaccines, with a few exceptions (such as IPV and pneumococcal polysaccharide vaccines, which may be given either SC or IM). Vaccine efficacy may also be reduced if not given by the recommended route. A 5 year old came in today for her preschool vaccines. She needed MMR and varicella. She has a broken arm which is in a cast. Can the anterolateral thigh be used to administer a subcutaneous vaccine in a 5 year old? Yes. There is no age limit for use of the anterolateral thigh for either subcutaneous or intramuscular vaccines. I have a 2-month-old child with a cast for hip dysplasia that completely covers the entire anterolateral thigh on both legs. She is not due to have it removed for 10 weeks. What options do we have for her injectable vaccines? Ideally, you can arrange to have the cast cut to administer vaccines in the anterolateral thighs. If that option is not available, the gluteal region can be used if not covered by the cast. There are no other sites we recommend for vaccination; however, the inactivated polio vaccine could be given subcutaneously in either arm, if the child is large enough. Rotavirus vaccine is given orally and should be administered. If vaccines cannot be given for the 10 weeks, please advise the family to keep people with any illness away from the child until she has been vaccinated. More information see ACIP's General Best Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. I need information about the administration of vaccines to 3-month-old conjoined twins (joined at the buttocks). For their routine immunization, do we provide one set of vaccinations or two, given that they are conjoined at the buttock but share no major organs? ACIP does not address this issue. However, CDC recommends that these children should each be vaccinated, notwithstanding they are conjoined. We believe even in conjoined twins who share organs and/or blood supply, vaccination of each child would also be indicated. The rationale is one cannot be sure, even in the latter case, that the common organs/blood supply would eliminate vaccine antigens less quickly, or the immune system(s) would respond adequately, to one dose of each vaccine for the two children. Therefore two doses seems appropriate, that is, one dose of each vaccine for each child. If I need to give more than 1 injection in a muscle, are certain vaccines best given at different anatomic sites? Since DTaP and pneumococcal conjugate (PCV) are the vaccines most likely to cause a local reaction, it is prudent to give DTaP and PCV in separate limbs (if possible), so there is no confusion about which vaccine caused the reaction. How many vaccines can be given during an office visit? With rare exceptions*, all vaccines can be administered at the same visit. There is no upper limit for the number of vaccines that can be administered during one visit. ACIP and AAP consistently recommend that all needed vaccines be administered during an office visit. Vaccination should not be deferred because multiple vaccines are needed. All live vaccines (MMR, varicella, live attenuated influenza, yellow fever, and oral typhoid) can be given at the same visit if indicated. If live vaccines are not administered during the same visit, they should be separated by 4 weeks or more. When giving several injections at a single visit, separate IM vaccines by at least 1 inch in the body of the muscle if possible to reduce the likelihood of local reactions overlapping. Here are some helpful site maps for different ages so you can record where shots were given: For infants and toddlers: eziz.org/assets/docs/IMM-718.pdf For older children: www.aimtoolkit.org/docs/Giving_all_the_doses_12mths.pdf For adults: www.eziz.org/assets/docs/IMM-718A.pdf For details see ACIP's General Best Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. *There are 3 exceptions to this general rule: 1) if both pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck) are indicated for a high-risk patient, these vaccines should not be given at the same visit. The PCV13 should be given first followed by PPSV23 at least 8 weeks later. If PPSV23 has already been given, wait 8 weeks (for a child) or 1 year (for an adult age 19 years or older) before giving PCV13 to avoid interference between the two vaccines. 2) A person with anatomic or functional asplenia or HIV should receive both PCV13 and meningococcal ACWY (MenACWY) vaccines. If Menactra brand (Sanofi) MenACWY is used, the person should first receive all recommended doses of PCV13 followed by Menactra at least 4 weeks later. Menveo (GSK) or MenQuadfi (Sanofi) MenACWY brands can be given at the same time or at any time before or after PCV13. 3) Cholera vaccine should be administered before TY21a vaccine, and 8 hours should separate cholera vaccine and the first dose of TY21a. A 5-year-old is in the office for vaccines and is due for MMR, polio, varicella, and DTaP. Is there a specific order I should be giving these vaccines? The Advisory Committee on Immunization Practices (ACIP) does not address this issue. There is no recommended order in which the vaccines should be given. A best practice strategy to decrease injection or procedural pain is to administer the vaccine that causes the most pain (stinging, for example) last. For more information on vaccine administration, please see the "Vaccine Administration" chapter of Epidemiology and Prevention of Vaccine-Preventable Diseases at www.cdc.gov/vaccines/pubs/pinkbook/chapters.html. Do we need to wait for the vaccine to reach room temperature before we administer it to a patient? With the exception of two vaccines used to prevent smallpox or monkeypox, there is no recommendation to wait until a vaccine reaches room temperature before administration. The vaccine should be administered as soon as it is prepared. The live smallpox (vaccinia) vaccine, ACAM2000 (Emergent Product Development Gaithersburg, Inc.) and the non-replicating, live smallpox and monkeypox vaccine, Jynneos (Bavarian Nordic) should be brought to room temperature before use, according to the package inserts for these two products. What is the acceptable volume for a single dose of immune globulin (IG) to inject into the deltoid muscle of a normal-weight adult? What is the acceptable volume for a single dose of IG to inject into the vastus lateralis of a normal-weight adult? Here are the suggested volumes: Deltoid: • Average 0.5 mL • Range 0.5–2 mL Vastus Lateralis: • Average 1–4 mL • Range 1–5 mL Infants and toddlers would fall at the lower end of the range, whereas adolescents and adults would generally fall on the higher end of the range. If all needed vaccines aren't administered during the same visit, does one need to wait a certain period of time before administering the other needed vaccines? All inactivated vaccines, including COVID-19 vaccines, can be given on the same day, or on any day before or after giving other inactivated or live vaccines. Early guidance from ACIP recommended against coadministration of COVID-19 vaccines with other vaccinations; however, ACIP updated its guidance in mid-2021 to state that these vaccines may be coadministered with other vaccinations when necessary. If two live vaccines are not given on the same day, they need to be spaced at least 4 weeks apart. As noted above, if both PCV13 and PPSV23 are indicated for a high-risk patient, these vaccines should not be given at the same visit. The PCV13 should be given first followed by PPSV23 at least 8 weeks later. If PPSV23 has already been given, wait 8 weeks (for a child) or 1 year (for an adult age 19 years or older) before giving PCV13 to avoid interference between the 2 vaccines. A person with anatomic or functional asplenia should receive both pneumococcal conjugate vaccine (PCV13) and meningococcal conjugate vaccines (MenACWY). If Menactra brand MenACWY is used the person should first receive all recommended doses of PCV13 then Menactra at least 4 weeks later. Menveo or MenQuadfi brands of MenACWY can be given at the same time or at any time before or after PCV13. What does "simultaneous administration" of vaccines mean? Does it mean the same day, hour, or what? Simultaneous means the same day—the same clinic day. If someone receives a vaccine in the morning and then another that same afternoon, it would be considered simultaneous administration. Some manufacturers' package inserts state that a vaccine should be used immediately after reconstitution. In the context of reconstitution and administration of vaccines, how does CDC define "immediately"? There are various requirements for the use of vaccines after reconstitution. Some manufacturers' package inserts require that the vaccine be used or discarded in varying time frames ranging from 24 hours after reconstitution to immediately after reconstitution. While the specific timeframes are simple to interpret, there can be some confusion as to what the requirement of "immediately" actually means. CDC considers "immediately" to be the reasonable time it takes to prepare and transport the vaccine to the patient to be administered. This would include any limited documentation that may be related to this process. It is up to the judgment of a provider to determine if a vaccine has not been used in the appropriate time. Some manufacturers have indicated to providers that "immediately" can be up to 30 minutes. The definition of "immediately" varies from manufacturer to manufacturer. Some do not have the data to put forth a general time frame as to what "immediately" means. CDC recommends that the provider contact the manufacturer any time (s)he has any question about whether or not the vaccine has been used in the appropriate time frame. Does live oral cholera vaccine (Vaxchora, PaxVax) need to be administered at an interval from other live oral or injectable vaccines? In general, no. According to ACIP's General Best Practice Guidelines for Immunization, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. So live oral cholera vaccine may be administered simultaneously or at any interval before or after administration of most other vaccines. One exception is Ty21a oral typhoid vaccine (Vivotif, Berna) and oral cholera vaccine. Oral cholera vaccine should be administered before Ty21a vaccine, and at least 8 hours should separate the cholera vaccine and the first dose of Ty21a. We have a nurse in one of our clinics who gave separate doses of hepatitis A and hepatitis B vaccine in the gluteus. Are the doses of each antigen considered invalid? If so, can they be repeated at any time or do I need to count the spacing between doses from the date when the invalid dose was administered? Although the gluteus muscle is not a recommended site for vaccination, in general, a dose given there can be considered valid. The exceptions to this general rule are hepatitis B and rabies vaccines, so the hepatitis B vaccine should not be counted in this situation. The hepatitis B vaccine can be repeated immediately. See the Advisory Committee on Immunization Practice's (ACIP) General Best Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. Is the "Z-track" method recommended for IM injections? ACIP does not address the use of this method for vaccination in its Best Practices Guidelines for Immunization (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html). If you choose to use this method, you should still adhere to the ACIP's recommendations regarding needle length and anatomical site. Is it safe to give a vaccine directly into an area where there is a tattoo? Both IM and SC vaccines may be given through a tattoo. Do you need to aspirate before giving a vaccination? No. ACIP does not recommend aspiration when administering vaccines because no data exist to justify the need for this practice. There are data that show that aspiration is more painful for the vaccine recipient. IM injections are not given in areas where large vessels are present. Given the size of the needle and the angle at which you inject the vaccine, it is difficult to cannulate a vessel without rupturing it and even more difficult to actually deliver the vaccine intravenously. We are aware of no reports of a vaccine being administered intravenously and causing harm in the absence of aspiration. While giving an injection, a nurse had blood return in the syringe upon aspirating. What should she have done with the vaccine? Although aspiration is not recommended, if you do aspirate and get a flash of blood, then the procedure is to withdraw the needle and start over. The syringe, needle, and contaminated dose of vaccine should be discarded in a sharps container, and a new syringe and needle should be used to draw up and administer another dose of vaccine. This is a waste of expensive vaccine that could be avoided by simply not aspirating. Is it necessary to wear gloves when we administer vaccinations? In general, no. Occupational Safety and Health Administration (OSHA) regulations do not require the wearing of gloves when administering vaccinations, unless the person administering the vaccine is likely to come into contact with potentially infectious body fluids or has an open lesion on their hand. If a healthcare worker chooses to wear gloves, he or she must change them between each patient encounter. In response to the 2020 COVID-19 pandemic, CDC has recommended the use of gloves when administering oral and intranasal vaccines to patients in communities where SARS-CoV-2, the virus that causes COVID-19, is circulating. Gloves are recommended to prevent contact with the recipient's potentially infectious mucous membranes or respiratory secretions. For more guidance on safe vaccination practices during the COVID-19 pandemic, see www.cdc.gov/vaccines/pandemic-guidance/index.html. The Immunization Action Coalition (IAC) has developed a handout on protective measures to take when vaccinating during the COVID-19 pandemic, available at www.immunize.org/catg.d/p2009.pdf. Is protective eyewear needed for those who administer vaccines so they can avoid blood spatter? ACIP does not specifically recommend eye protection when administering vaccines to prevent exposure to blood spatter. In response to the COVID-19 pandemic, CDC has made recommendations concerning the use of protective eyewear by immunization providers in communities where SARS-CoV-2, the virus that causes COVID-19, is circulating. In areas with moderate to substantial community transmission of SARS-CoV-2, healthcare providers should wear eye protection given the increased likelihood of encountering asymptomatic COVID-19 patients. In areas with no or minimal community transmission of SARS-CoV-2, universal eye protection is considered optional, unless otherwise indicated as a part of standard precautions. For more guidance on safe vaccination practices during the COVID-19 pandemic, see www.cdc.gov/vaccines/pandemic-guidance/index.html. The Immunization Action Coalition (IAC) has developed a handout on protective measures to take when vaccinating during the COVID-19 pandemic, available at www.immunize.org/catg.d/p2009.pdf. It is fall 2021 and we are preparing our supplies for an immunization clinic in the context of COVID-19. Do surgical masks or cloth face coverings need to be worn in immunization settings while COVID-19 is circulating? Are N95 respirators recommended to be worn while administering any vaccinations? In order to reduce the risk of exposure to SARS-CoV-2, the virus that causes COVID-19, CDC recommends that all health care providers administering vaccines in any setting wear a medical face mask at all times and that they implement policies for the use of cloth face coverings by all patients age 2 years and older who can tolerate them. Administration of oral or nasal spray vaccines is not considered to be an aerosol generating procedure and N95 respirators are not recommended for vaccine administration. See the next question for links to more information. Where can I find current information on how to protect myself and my patients when administering vaccines during the COVID-19 pandemic? CDC has published guidelines for safe vaccine administration during the COVID-19 pandemic that will be updated as needed. These guidelines focus on reducing the risk of SARS-CoV-2 transmission while in the location where immunizations are being given and during vaccine administration and can be found here: www.cdc.gov/vaccines/pandemic-guidance/index.html. IAC has assembled key resources, handouts and links related to COVID-19 and vaccination on our Vaccination and COVID-19 page, www.immunize.org/vax-and-covid-19/, and in our Ask the Experts section on COVID-19 and Routine Vaccination, at www.immunize.org/askexperts/experts_covid19.asp. Some single-dose manufacturer-filled vaccines come with an air pocket in the syringe chamber. Do we need to expel the air pocket before vaccinating? No. You do not need to expel the air pocket. The air will be absorbed. This is not true for syringes that you fill yourself; you should expel air bubbles from these syringes prior to vaccination to the extent that you can do so. I've seen the recommendation stating air bubbles in manufacturer-filled syringes do not need to be expelled. Can you explain why those air bubbles can be injected but air bubbles in user-filled syringes must be expelled? It is not wrong to expel the air from syringes filled by manufacturers, but typically it is such a small amount of air (0.2cc–0.3cc) that it is CDC's opinion that it would not cause a problem. When the syringe is inverted during an injection, that small amount of air would typically just clear the medication from the needle. This is based on the recommendation that when the Z-track method is used for intramuscular injection of irritating medication (e.g., iron preparations), the guidance is to leave 0.2cc–0.3cc in the syringe to be sure that all of the medication leaves the needle and is not tracked back through subcutaneous tissue as the needle is withdrawn. While the Z-track injection technique is not recommended for vaccine administration, the Z-track method demonstrates the acceptability of leaving a very small amount of air in the syringe for intramuscular injections. CDC does, however, recommend that when drawing vaccine from a vial into a regular syringe, the air be expelled because the amount of air drawn into the syringe may be larger than the amount in a manufacturer-filled syringe. Expelling the air is part of general medication guidelines for drawing medication into a syringe. If a patient is not able to receive rotavirus vaccine orally, can we give it through a G-tube? You can give rotavirus vaccine through a tube as long as the child is otherwise eligible. If the lymph nodes under a patient's arm were surgically removed, should we avoid giving vaccines in that arm? We are aware that some surgeons advise against vaccination in an arm where lymph nodes were dissected. ACIP does not address this, so feel free to use your professional judgment in determining whether to use the arm that was operated on, the other arm (if not affected), or the anterolateral aspect of the thigh, which is an acceptable secondary route for adult immunization. What are the special recommendations for administering intramuscular injections in people with clotting disorders? This issue is discussed in ACIP's Best Practices Guidelines for Immunization (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html). Intramuscular (IM) injections should be scheduled shortly after antihemophilia therapy or prior to a dose of anticoagulant. For both IM and subcutaneous (SC) injections, a fine needle (23 gauge or smaller) should be used and firm pressure applied to the site, without rubbing, for at least 2 minutes. Providers should not administer a vaccine by a route that is not approved by the FDA for that particular vaccine (e.g., administration of IM vaccines by the SC route). We have a question concerning delaying vaccinations for an infant born to a heroin-addicted mother. We had a foster parent come into our health department requesting only certain vaccines for a 3-month-old, stating that the private physician recommends delaying the schedule due to the possible residual effects of the heroin. The baby appeared to be healthy. Heroin use or addiction of the mother is not a reason to delay vaccination of an otherwise healthy infant. Is it okay to draw up vaccines at the beginning of the shift? If it isn't, how much in advance can this be done? The ACIP discourages the practice of prefilling vaccine into syringes, primarily because of the increased possibility of administration and dosing errors. An exception may be considered when only a single type of vaccine is to be administered during a clinic (e.g., influenza). Another reason to discourage the practice in general is that some vaccines have a very limited shelf life after reconstitution. If the reconstituted vaccine is not used within the designated time period, it must be discarded. A chart of the time allowed between reconstitution and use, "Vaccines with Diluents: How to Use Them," is available at www.immunize.org/catg.d/p3040.pdf. For more information on prefilling syringes, please read www.immunize.org/technically-speaking/20110901.asp. If you place a needle on a manufacturer-filled syringe and then don't administer the vaccine, how long can you store the syringe with the needle attached? In general, a vaccine should not be prepared until the provider is ready to administer it to a patient. This is because once the syringe cap is removed or a needle is attached, the sterile seal is broken. However, if a sterile seal has been broken, staff should be sure to maintain the syringe at the appropriate temperature and either use it or discard it at the end of the clinic day. This issue is addressed in the CDC Storage and Handling Toolkit, available at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, page 20. My nurse removed the protective cap from a preservative-free single dose vial, but the vial was not used. How long can we keep a vial of vaccine after we remove the protective cap of a preservative-free vial of vaccine? Removing the protective cap increases the likelihood the septum or stopper could be punctured. The puncture may not be visible. It is important to ensure that the rubber seal on single-dose vials is not punctured because single-dose vials do not contain a preservative. Once the protective cap has been removed, the vaccine should be discarded at the end of the workday because it may not be possible to determine if the rubber seal has been punctured. For additional details, see CDC's Vaccine Storage & Handling Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. Is it necessary to allow alcohol to dry completely on a patient�s skin prior to injection? It is prudent to allow the alcohol to evaporate, but it is unlikely that the small amount residual alcohol on the skin will affect the vaccine or increase the risk of an adverse reaction. Is it recommended to use a new alcohol swab to cleanse the skin before administering a vaccine, or can we swab the skin with the same alcohol swab that we used to wipe off the stopper on the vial? You should use separate alcohol wipes to clean the vial top and the patient's skin. I know that it is advisable to clean the vaccine vial stopper with an alcohol wipe after removing the protective cap from a vaccine or diluent vial. Do you have to wait for the alcohol to dry before you insert the needle in to the stopper? The stopper of a single-dose vial is often assumed to be sterile. However, not all vaccine manufacturers guarantee the tops of unused vials are sterile, and the manner in which the cover over the stopper is removed can potentially contaminate the stopper. Therefore, using friction and a sterile alcohol pad to swab the stopper may help to assure aseptic technique in preparing the single-dose vial prior to inserting a sterile syringe. Alcohol evaporates quickly and will dry while the needle is being prepared for insertion into the vial. In cleaning the vaccine vial stopper or the patient's skin, is it okay to use a non-sterile cotton ball or do we need to use a pre-packaged sterile alcohol prep pad? Using a pre-packaged sterile alcohol prep pad is recommended to maintain aseptic technique. Not only are cotton balls not sterile, but neither is a bottle of sterile alcohol, once it's opened. Some single dose vials (SDV) contain more than the recommended dosage of the vaccine. Should we administer the recommended dose of the vaccine, or the entire contents of the vial even if it contains more than the recommended dose? In general the entire volume should be used even if it is a little more than 0.5 mL. Discarding the excess vaccine is not required or recommended. An exception to this is recombinant zoster vaccine (RZV; Shingrix, GSK). The RZV adjuvant solution may contain up to 0.75 mL of liquid. The entire volume of the adjuvant solution should be withdrawn and used to reconstitute the lyophilized vaccine. After mixing, withdraw the recommended dose of 0.5 mL. Any reconstituted vaccine left in the vial should be discarded. Where can I obtain standing orders for vaccination? The Immunization Action Coalition (IAC) has developed suggested standing orders for all vaccines commonly given to children and adults. They are based on CDC's Advisory Committee on Immunization Practices (ACIP) recommendations. You can find the standing orders and protocols for medical management of vaccine reactions at www.immunize.org/standing-orders. What is the provider's liability when using standing order protocols? While you did not say this explicitly, we assume the concern is about a vaccine injury in a person who was vaccinated using a standing order. Of course, as long as the person is properly screened for contraindications and precautions, an injury from a vaccine is very unlikely. In the event that an injury does occur, the National Vaccine Injury Compensation Program (VICP) provides liability protection for the vaccinator and the clinician who signed the standing order for any vaccine that is covered by the vaccine injury compensation program (all vaccines that are routinely administered to children are covered by the program for all ages of patients). More information about the VICP is available on their website at www.hrsa.gov/vaccinecompensation/index.html. A 2009 article in The Lancet reported that infants who received 3 doses of paracetamol following immunization had reduced immune responses to certain vaccines. Based on these findings, should we stop recommending acetaminophen for fever or discomfort after infant immunizations? Findings of this study discourages the prophylactic use of paracetamol (similar to acetaminophen) prior to or immediately following vaccination. Acetaminophen can be used to treat pain or fever if it should occur following vaccination. ACIP's General Best Practices Guidelines for Immunization state: "Evidence does not support use of antipyretics before or at the time of vaccination; however, they can be used for the treatment of fever and local discomfort that might occur following vaccination. Studies of children with previous febrile seizures have not demonstrated antipyretics to be effective in the prevention of febrile seizures." For more information on this issue, see Methods for Alleviating Discomfort and Pain Associated with Vaccination at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. What guidance is there for preventing patients from fainting after vaccination? All providers who administer vaccinations should be aware of the potential for syncope (fainting) after vaccination and take appropriate measures to prevent it. Thus, clinicians should (1) make sure that people who are being vaccinated are always seated; (2) be aware of symptoms that precede fainting (weakness, dizziness, pallor, etc.); and (3) take appropriate measures to prevent injuries if such symptoms occur. IAC has two pertinent educational pieces for healthcare professionals: "Medical Management of Vaccine Reactions in Children and Teens" at www.immunize.org/catg.d/p3082a.pdf and "Medical Management of Vaccine Reactions in Adult Patients" at www.immunize.org/catg.d/p3082.pdf. Since 2005, VAERS has received an increasing number of reports of syncope, coinciding with the licensure of three vaccines for adolescents—HPV, meningococcal conjugate, and Tdap. Fainting among girls and young women ages 11–18 accounted for most of the increase. Serious injuries have occurred, including one fatality from intracranial hemorrhage caused by head trauma. The May 2, 2008, MMWR included a summary of findings on the increase in fainting after vaccination (see www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm). In people for whom vaccination time and fainting time were reported, it was discovered that 80% occurred within 15 minutes of receiving the vaccine. Vaccine providers should strongly consider observing vaccinated people for 15 minutes after vaccination in accordance with ACIP's General Best Practices Guidance for Immunization (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html). This is particularly important when vaccinating adolescents and young adults. CDC has posted frequently asked questions on this topic at www.cdc.gov/vaccinesafety/Concerns/syncope_faqs.html. Are vaccine diluents interchangeable? Diluents are not interchangeable, except for the sterile water used in Merck's measles-mumps-rubella (MMR), measles-mumps-rubella-varicella (MMRV), and varicella vaccines. No other diluent can be used for these vaccines, and these diluents must not be used to reconstitute any other lyophilized vaccine. If the wrong diluent is used, the vaccination should always be repeated. If an inactivated vaccine is reconstituted with the wrong diluent and is administered, the dose is invalid and should be repeated as soon as possible. If a live vaccine is reconstituted with the wrong diluent and is administered, the dose is invalid. If the dose can't be repeated on the same clinic day, it needs to be repeated no earlier than four weeks after the invalid dose. This spacing is due to the effects of generating a partial immune response that could suppress the live replication of subsequent doses, even of the same live vaccine. Is it recommended to change needles after a vaccine dose has been drawn into a syringe? No. It is also unnecessary to change the needle if it has passed through two stoppers, which is done when a lyophilized vaccine is reconstituted. Changing needles is a waste of resources and increases the risk of needle stick injury. When patients need multiple vaccines (such as influenza and pneumococcal), can we just combine them in the same syringe? Absolutely not. No vaccines should ever be mixed in the same syringe unless the combination has been specifically approved by the FDA. The needle came loose while I was injecting a dose of vaccine, and approximately half the dose was lost. Should we revaccinate the patient? If so, when? When injectable vaccine volume is lost (patient moves, syringe leaks), it may be difficult to judge how much vaccine the patient actually received. Use your discretion to determine whether an adequate dose was given. In general, you should treat this as a nonstandard injectable dose and should not count it. If it was an inactivated vaccine, you should re-immunize the person as soon as possible. In the case of Shingrix (RZV; GSK) if the person is still in the office the dose can be repeated immediately; however, if the repeat Shingrix dose cannot be given on the same day CDC recommends that it should be given 4 weeks after the invalid dose. If it was a live vaccine, you can give another dose if you detect the error on the same clinic day; otherwise, you should wait 28 days to give the next dose. However, if part of a dose of an oral vaccine (rotavirus) was spit out by an infant, count the dose and do not administer a second dose. If a person sneezes after live attenuated influenza vaccine (Flumist; AstraZeneca) the dose can be counted as valid. If a patient pulls away during administration of a vaccine and the needle comes out, is it okay to reintroduce the same needle and finish the injection? No. The needle should be considered to be contaminated. The needle and syringe should be discarded. A new syringe, needle, and dose of vaccine should be used. Generally, a full repeat dose should be given, but you may use your clinical judgment to decide whether an adequate dose was administered before the patient pulled away. We run a student health center and are wondering what the position is on discarding empty vaccine vials. Do they need to go in a sharps container after they are drawn up or can they go in the trash? Empty or expired vaccine vials are considered medical waste and should be disposed of according to state regulations. Vaccine Administration Errors Back to top We received a report of an infant who received rotavirus vaccine intramuscularly rather than orally. Is this dose valid? If not, when should it be repeated? The rotavirus vaccine dose given by the intramuscular route is not valid and should be repeated by the oral route as soon as possible. In a review of such rotavirus vaccine administration errors, there usually were not adverse reactions, and those documented were limited to local reactions and general, brief irritability. Please see www.cdc.gov/mmwr/pdf/wk/mm6304.pdf, page 81, for more information. Please take steps to ensure that such vaccine administration errors are avoided in the future. This event should be reported to the Vaccine Adverse Event Reporting System at https://vaers.hhs.gov even if an adverse reaction does not result from it. What should we do if a dose of expired vaccine is given to a patient? The dose should be repeated. If the expired dose is a live virus vaccine, you should wait at least 4 weeks after the previous (expired) dose was given before repeating it. If the expired dose is not a live vaccine, the dose should be repeated as soon as possible. Although simply repeating the dose is preferred, serologic testing to check for immunity after certain vaccinations (e.g., measles, rubella, varicella, hepatitis A) may be accepted. MMRV was mistakenly given to a 31-year-old instead of MMR. Can this be considered a valid dose? Yes, however, this issue is not addressed in the 2010 MMRV ACIP recommendations. Although this is off-label use, CDC recommends that when a dose of MMRV is inadvertently given to a patient age 13 years and older, it may be counted towards completion of the MMR and varicella vaccine series and does not need to be repeated. An expired dose of ProQuad (MMRV, Merck) was given to a patient. We assume that the repeat dose should be given in three months because the spacing between doses of a combination vaccine depends on the longest minimum interval of a component (in this case the varicella vaccine component). Is this correct? In the case of an expired live vaccine, the issue is not necessarily the routine minimum interval (three months in the case of varicella and ProQuad vaccines), but the interval that would prevent viral interference if the expired vaccine happened to be still viable. This interval is considered to be four weeks (28 days). The repeat dose should be administered four weeks after the expired dose. What should we do if we give an injection by the wrong route (SC instead of IM)? Your practice should put procedures in place to ensure that you always give vaccines by the recommended route because data regarding safety and efficacy of alternate routes are limited. If this does inadvertently happen, ACIP and/or CDC recommends that if hepatitis B, rabies, HPV and inactivated influenza vaccines are administered subcutaneously the doses should not be counted as valid and should be repeated. ACIP states that If PCV13, Hib, and/or DTaP are administered by the subcutaneous route, providers have the discretion to repeat the doses. There is no minimum interval between the invalid dose and the repeat dose. ACIP and/or CDC recommends that if HepA, MenACWY, IPV, PPSV23, COVID-19, and RZV vaccines are administered subcutaneously, the doses can count and do not need to be repeated. ACIP/CDC has no recommendation for Tdap, Td, MenB, Typhim VI, or JE-VC. One of our staff gave a dose of pediatric hepatitis A vaccine to an adult patient by mistake. How do we remedy this error? In general, if the error is discovered on the same clinic day, you can administer the other "half" of the dose on that same day. If the error is discovered later, the dose should not be counted, and then the person should be recalled to the office and given a full age-appropriate repeat dose. There are, however, two exceptions to the general rule: (1) If a patient sneezes after receiving nasal-spray live attenuated influenza vaccine, count the dose as valid. (2) If an infant regurgitates, spits, or vomits during or after receiving oral rotavirus vaccine, count the dose as valid. If you give more than an age-appropriate dose, count the dose as valid and notify the patient/parent about the error. Using larger than recommended dosages can be hazardous because of excessive local or systemic concentrations of antigens or other vaccine constituents. Avoid such errors by checking the vaccine vial label 3 times.   A dose of Kinrix (DTaP-IPV; GSK) should have been administered to a 4-year-old, but Pentacel (DTaP-IPV-Hib; Sanofi Pasteur) was administered instead. Does the dose of DTaP count? Yes. The DTaP in the Pentacel can be counted. Although Pentacel is licensed as a 4-dose series and this may represent a fifth dose of Pentacel (in which case it would be off-label use), the dose of DTaP counts as the fifth dose of DTaP. A dose of pneumococcal conjugate vaccine was administered into my patient's dialysis port. Does this dose count? There are no data on the effectiveness of pneumococcal conjugate vaccine given by the intravenous route. The patient has renal disease, so it is important to ensure that the dose they receive is effective. CDC recommends repeating the dose. A 2-month-old was mistakenly given PPSV23 instead of PCV13. What should be done? PPSV23 is not effective in children younger than 24 months of age. PPSV23 given at this age should not be considered to be part of the pneumococcal vaccination series. PCV13 should be administered as soon as the error is discovered. Any time the wrong vaccine is given, the parent/patient should be notified. Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance. Although PCV13 and PPSV23 should not be administered at the same visit, CDC does not recommend repeating either vaccine dose should this occur. You should inform the patient of the error and let them know that they will not need to repeat either dose. A 60-year-old patient was inadvertently given varicella vaccine instead of zoster vaccine. Should the patient still be given the zoster vaccine? If so, how long an interval should occur between the 2 doses? CDC recommends that if a provider mistakenly administers varicella vaccine to a person for whom zoster vaccine is indicated, no specific safety concerns exist, but the dose should not be considered valid. Recombinant zoster vaccine (RZV; Shingrix, GSK) should be administered at least 8 weeks after receipt of the varicella vaccine. However, if RZV is administered less than 8 weeks after the varicella vaccine, it does not need to be repeated. A second dose of RZV should be given 2–6 months after the first dose of RZV. Avoid such errors by checking the vial label 3 times to make sure you're administering the product you intended. If RZV (Shingrix) is erroneously given to a child for prevention of varicella, the dose is invalid, but is there a waiting period before a valid dose of varicella vaccine can be given? Is it OK to give a dose of varicella vaccine as soon as the error is discovered? There is no waiting period. The varicella vaccine dose can be given at any time after the RZV dose. While giving a dose of RZV (Shingrix) the syringe came loose from the needle and part of the dose was lost. Will the patient be protected with this partial dose or does it need to be repeated? A dose less than the full 0.5 mL dose is not valid and should be repeated. If the patient is still in the office the dose can be repeated immediately. If the repeat dose cannot be given on the same day CDC recommends that it should be given 4 weeks after the invalid dose. My medical assistant inadvertently administered a 0.5 mL dose of the RZV (Shingrix) diluent only. The dose did not contain any antigen. When can we administer a properly reconstituted dose? The CDC zoster subject matter experts recommend that in this situation you should wait 4 weeks before giving a repeat dose. Several doses (antigen and diluent) of RZV (Shingrix) were mistakenly stored in our office freezer. One of these doses was administered to a patient. Is this dose valid and if not, when can it be repeated? Any RZV, either antigen or diluent, that is exposed to freezing temperature should not be used. If a dose exposed to freezing temperature is given to a patient the dose should be considered invalid and should be repeated 4 weeks after the invalid dose. Back to top This page was updated on October 3, 2022. This page was reviewed on August 15, 2021.