Prevent Pitfalls With Vaccines and Treatments for COVID-19

Mishaps with COVID-19 vaccines and treatments are starting to hit "top 10" lists of med errors.

The mRNA COVID-19 vaccines are being prepped incorrectly...leading to people getting too much or too little vaccine.

The Pfizer-BioNTech and Moderna vaccines BOTH come as liquids.

But Pfizer-BioNTech's MUST be diluted prior to administration.

Be vigilant to ensure each vial of the Pfizer-BioNTech vaccine is diluted with 1.8 mL of preservative-free normal saline.

In some cases, patients have received doses from a vial that was diluted with just 1 mL...or not diluted at all.

Bamlanivimab is being confused with belimumab (Benlysta) injectable lupus treatment...causing patients to get the wrong med.

This isn't surprising, since the med names, doses, and administration are similar.

But it is concerning. Belimumab is not a commonly used med...and it can cause serious side effects, such as anaphylaxis.

Continue scanning bar codes and reading labels carefully...and using other strategies, such as separate avoid mix-ups.

Speak up if anything seems "off." In a recent case, belimumab was ordered for four COVID-19 patients...which should have been a red flag something was wrong.

Casirivimab/imdevimab has risks for incorrect well as look-alike errors.

The components come in separate vials...which must be combined before administration. Plus the vial labels may not have functioning bar codes or other key info.

If needed, add labels to clearly identify the meds...with med name, strength, and a scannable bar code.

And separate casirivimab/imdevimab from mRNA COVID-19 vaccines. They come in the same size vials...with red caps.

Remdesivir formulations are causing prep errors...because it comes as a solution and a lyophilized powder.

Either form can be used for adults...but the solution is NOT for most kids.

Use strategies such as labels or shelf tags to ensure pediatric doses are only prepped with remdesivir powder.

Get our tech tutorial, Preventing Med Errors, for more safety strategies you can use during the pandemic and beyond.

Key References

  • ISMP Med Safety Alert! Acute Care 2021;26(1):1-6
  • ISMP Med Safety Alert! Acute Care 2019;24(20):1-5; AA1-AA4
  • ISMP Med Safety Alert! Acute Care 2020;25(25):1-6
Hospital Pharmacy Technician's Letter. March 2021, No. 370328

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