ce CONTINUING EDUCATION
• The right patient • The right drug • The right dose • The right route (and site) • The right time.
• Poor storage practices allowing for a vaccine to be intermin - gled with other drugs resulted in the administration of insulin instead of the intended hepatitis B vaccine. Sadly, four of these mistakes resulted in the death of the patients. ISMP notes another fatal error where the diluent for the measles vaccine was replaced with a paralyzing agent, atracurium. • Giving a vaccine to a patient who was not eligible due to age was reported. The influenza nasal vaccine is not to be given to anyone over the age of 49, but mis- calculation of age or miscommunication of the correct vaccine resulted in patients over the age of 49 receiving this vaccine. ISMP notes that language barriers can also be a challenge in calculating patient age and determin- ing the appropriateness of a vaccine. For example, the Flublok quadrivalent vaccine was administered to chil- dren under the age of 18, which is also a contraindication. • Not checking the immunization registry system resulted in patients a) receiving an additional dose of a vaccine they had already received, b) receiving a second dose in a series too soon, or most commonly, c) not receiving the second or third dose in a series because the need for these addi- tional doses was not noted or acted upon. For example, the Hepatitis B vaccine requires 3 doses: day one, three months from day one, and six months from the first date of injection. Patient Positioning revisited The previous section on patient positioning discussed safety for the vaccine administrator. The requirement that the patient be seated or lying down is also a safety mandate for the patient. After all, fainting during vacci- nation may cause a patient to fall and create an injury. A standing patient may also attempt to pull away from the administrator. This movement can increase the risk of missing the target zone for injection. If the vaccine is administered too high, SIRVA may be the result. If the motion causes the vaccine to be adminis- tered too low, nerve damage is possible. The movement may also cause the vaccine not to be presented into the muscle, resulting in decreased vaccine efficacy. Movement during a subcutaneous injection may cause skin ripping. Considerations for patient positioning need to include the chair or seating chosen. Does the chair have handles to assist the patient in standing when the procedure is complete? Is the seat- ing sufficient to hold patients who weigh over 250 pounds? When vaccinating patients seated in wheelchairs, the wheels should be locked to avoid the chair moving and causing vaccine injury. Another source of motion can occur when vaccinating patients in their vehicles. For safety and for efficiency, many facilities are offering “drive-up” or “parking lot” vaccinations. The pharmacy technician who is providing vaccines to patients in vehicles should insist that the vehicle be placed into park and turned off to prevent the vehicle from moving during the procedure. If the driver of the vehicle is unwilling to following these guide- lines, the injection should be refused, and the patient should be instructed to enter the facility to receive the vaccination.
The right patient includes assuring that the correct patient has been identified. It also reminds a technician that the patient must be “right” to receive this vaccine. Is the vac- cine age restricted, as it is with nasal influenza? Does the patient meet the age requirements on the labeling? The right drug means that the correct vaccine has been selected. A careful triple check system will help avoid errors at this step. Does the vaccine match the VIS pro- vided to the patient? Does the vaccine match the order verified by the pharmacist? Does the vaccine match what the patient says that s/he is expecting? The ISMP reports that patients have received insulin instead of a vaccine because of poor storage decisions and failure to read labels. The right dose involves verifying that the proper volume has been drawn into the syringe. Remember, bubbles in the syringe decrease the amount of vac- cine given to the patient. If the vaccine needs to be reconstituted, does the diluent match the vaccine? Patients have died from improper reconstitution using the wrong diluent. The right route refers to more than simply know - ing that most vaccines are injected. The right route also includes providing the injection into the right muscle and doing that safely. As previously discussed, SIRVA can be avoided with proper technique and attention to detail. The right time encompasses several “times.” Is the timing correct based on the ACIP dosing schedules? Is the timing correct based on the date of a previous vaccine? Is the timing correct as determined by the expiration of the vaccine? This may mean the expiration date presented by the manufac- turer. Many vaccines expire quickly when a multi-dose vial has been entered, some as quickly as 6 hours later. Warming a vaccine to room temperature hastens the expiration date. Warnings from the ISMP report on causative factors for errors in influenza vaccine administration include: • Look-alike names, look-alike labels, and look-alike pack- aging. A pharmacy technician can combat each of these problems by managing the storage of the vaccines, the labeling of refrigerator or freezer compartments, and using a triple-check system. Check the vaccine claimed from the refrigerator or freezer against the order (not the label). Then, check the vaccine against the order when drawing up from a vial or preparing to administer. Finally, check the vaccine against the VIS provided to the patient before administering. Many influenza vaccine trade names start with FLU (Fluzone, Fluarix, Flublok, etc.), so it is important that the verification process is designed to avoid any mistakes. The ISMP report also notes the inadvertent administration of Havrix instead of Fluarix and the administration of Boostrix instead of Fluarix.
CPhT CONNECT www.pharmacy technician.org
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