Safeguard Patients During COVID-19 Immunization Campaigns

Pharmacy TimesMarch 2021
Volume 89
Issue 03
Pages: 46

Shoulder injuries are a real concern because some health care workers may be new to administering vaccines.

As our nation conducts a large-scale coronavirus disease 2019 (COVID-19) immunization campaign, it is critically important for health care workers who administer the vaccine to understand proper intramuscular (IM) administration technique to avoid a disabling and preventable occurrence known as shoulder injury related to vaccine administration (SIRVA).

This is especially important because health care workers who may not normally give vaccinations may be called upon to help administer the new COVID-19 vaccines.

SIRVA is a shoulder injury triggered by the incorrect injection of a vaccine into the shoulder capsule (joint) rather than the deltoid muscle. It is caused by using an incorrect IM injection technique or improperly landmarking the IM injection site (the deltoid muscle) resulting in the unintended injection of the vaccine and/or trauma from the needle into and around the underlying bursa of the shoulder. The resulting inflammatory process causes injury to the musculoskeletal structures of the shoulder, such as bursae, ligaments, and tendons.1-3

Symptoms of SIRVA include persistent shoulder pain, limited range of motion, and weakness. These typically develop within hours to a few days after receiving a vaccination. These symptoms do not improve with OTC analgesics. The resulting chronic shoulder pain and inability to carry out daily activities that were possible prior to vaccination often lead patients to seek medical intervention. Patients are often diagnosed with inflammatory shoulder injuries, such as adhesive capsulitis, bursitis, frozen shoulder syndrome, and rotator cuff tears. These do not appear any different than routine shoulder injuries, except that the shoulder symptoms started within days of an IM deltoid vaccination.1

How To Prevent SIRVA

The key to avoiding SIRVA is to recognize the anatomical landmarks
for identifying the deltoid muscle and to use proper IM administration technique. Proper landmarking of the deltoid muscle requires determining the lower and upper borders of a safe injection zone. First, the patient’s shoulder should be exposed completely. When a shirt cannot be removed, the arm should be removed from the sleeve or the sleeve should be rolled up, rather than pulling the shirt’s neck over the shoulder. To ensure the injection is given below the shoulder capsule, measure 2 to 3 finger widths from the acromion (bony prominence above the deltoid) to identify the upper border of the injection zone. The lower border can be marked by
the armpit to ensure that the injection is not inserted below the deltoid muscle. Eyeballing the injection site is not acceptable. The forefinger and thumb can be used to make a V to outline the deltoid muscle and keep the injection zone visible before injecting the needle at a 90-degree angle. Injections too close to the shoulder capsule can lead to SIRVA. Injections below or too far to the side of the deltoid muscle can hit the radial or axillary nerve, respectively, which can result in neuropathy or paralysis.1

Multiple resources related to proper vaccination techniques are provided by the Centers for Disease Control and Prevention and the Immunization Action Coalition.2,3 Many of these resources, including checklists, e-learning with continuing education credits, and videos, have been recently updated and are applicable to the COVID-19 vaccination campaign. Additionally, the University of Waterloo School of Pharmacy in Ontario, Canada, offers a helpful infographic on proper landmarking to prevent SIRVA. (

Error Reporting is Mandatory

As noted in the fact sheets for the COVID-19 vaccine products available under an emergency use authorization (EUA) from the United States Food and Drug Administration, reporting of adverse events (AEs), including medication errors, is mandatory. Providers or their designees must report all medication errors and serious AEs using the methods noted in the specific product fact sheet and within the specified period. Errors related to the COVID-19 vaccines must be reported to the Vaccine Adverse Event Reporting System (VAERS; Consult the specific EUA product’s fact sheet for the required reporting method.

In addition, consider informing the Institute for Safe Medication Practices (ISMP) about any actual or potential errors involving these vaccines via email ( or the ISMP website ( However, with EUA vaccines, reporting to the ISMP will not replace the need for mandatory reporting to VAERS.


Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.


  1. Bancsi A, Houle SKD, Grindrod KA. Shoulder injury related to vaccine administration and other injection site events. Can Fam Physician. 2019;65(1):40-42.
  2. Wexler D. Prevent shoulder injuries caused by missing the deltoid muscle when injecting vaccines! Immunization Action Coalition. Updated November 19, 2020. Accessed January 10, 2021.
  4. Wexler D. Let’s get it right! how to avoid shoulder injury with deltoid intramuscular injections. Immunization Action Coalition. Updated November 8, 2018. Accessed January 10, 2021.
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