Vaccine Errors Decrease Following Monthly Inspections, Process Standardization


Regular vaccine workflow re-education helps promote standard workflows and prevent vaccine errors.

Monthly medical inspections, as well as standardizing vaccine screening and double verification methods in the ambulatory care environment, helped to reduce vaccine-related administration errors, according to a study presented at ASHP Midyear 2021. The investigators strongly recommended annual or biennial vaccine workflow re-education to promote standard workflows and prevent vaccine errors.

The investigators aimed to address opportunities for improving vaccine administrative activities in the ambulatory care setting. A vaccine workgroup was assembled in December 2018 to design a plan for improving vaccine storage, preparation and administration, and reducing vaccine-related errors. The committee consisted of ambulatory primary care, infectious disease, medication utilization, and EPIC IT analyst team members, including physicians, pharmacists, and medical assistants.

The vaccine administration screening process was changed from a vaccine-specific EMR documentation tool that required IT maintenance for any changes in vaccine products and/or clinical guideline recommendations to a non-vaccine-specific tool that focuses on the review of respective vaccine information sheets. According to the study authors, this change was implemented enterprise-wide in the ambulatory environment.

Further, a best practice vaccination workflow, including independent double verification, was developed and disseminated for care team education. An established monthly medication inspection process, previously only implemented in hospital-based clinics, was expanded to all clinics across the enterprise.

According to the results of the study, overall adherence to the vaccine screening and verifications processes has improved from September 2020 to May 2021. Screening process adherence increased from 68% to 82%, and verification process adherence increased from 20% to 69%.

Furthermore, both the total number of vaccine errors as well as the rate of vaccine errors have declined over the past 3 flu seasons, from 41 errors of 101,860 vaccines in the 2018-2019 flu season to 15 errors of 146,842 vaccines in the 2020-2021 flu season. The investigators found that incorrect dosing and expired medication administration errors saw the greatest reduction, and level 3 and 4 errors appear to have been more specifically reduced following the 2020 vaccine workflow re-education.


Weitzman, ER. Shot at vaccine error reduction: Improving and standardizing vaccine processes in ambulatory clinics. Presented at: ASHP Midyear 2021. Accessed December 1, 2021.

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