Refrigerator Mix-ups
Some hospitals provide boxes of influenza vaccine to the emergency department and nursing units to store in their unit-based medication refrigerator to facilitate vaccine distribution. Although we would much rather see patient-specific doses dispensed from the pharmacy, if your facility does this, you need to be certain that there are no other refrigerated look-alike items (with container volume, shape, color, or labeling) with which the vaccine might be confused.
The Institute for Safe Medication Practices published an article in 2014 about a measles vaccine diluent that was confused with atracurium, which resulted in the deaths of 15 children in Syria. But we also listed similar mix-ups between neuromuscular blockers and influenza vaccine in the United States, at least one of which was a fatal event. All of these products were stored near one another in hospital refrigerators. In addition, we’ve received multiple reports of influenza vaccine being mixed up with insulin, and, just last month, with tuberculin purified protein derivative (PPD), which led to 41 correctional officers receiving intradermal injections of influenza vaccine.
Where are vaccines stored in your organization and what strategies are in place to prevent mix-ups with potential dangerous medications?
Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.
