The National Alert Network (NAN), a coalition of members of the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), has issued an alert to make vaccine providers aware of reports of accidental mix-ups between the influenza and COVID-19 vaccines. The alert is based on 16 cases reported to the Institute for Safe Medication Practices (ISMP) error reporting programs. Most of the reports ISMP has received involve administration of one of the COVID-19 vaccines instead of an influenza vaccine; in three cases, patients received an influenza vaccine instead of a COVID-19 vaccine.

The alert includes potential contributing factors that may lead to mix-up errors that vaccine providers should be aware of, as well as recommendations for preventing vaccine mix-ups.

The NAN, in cooperation with ISMP and ASHP, distributes NAN alerts to warn healthcare providers of the risk for medication errors that have caused or may cause serious harm or death, or to warn them about new findings that could cause harm and are being reported with unusual frequency. NCC-MERP, ISMP, and ASHP encourage the sharing and reporting of medication errors both nationally and locally, so that lessons learned can be used to increase the safety of the medication use system.

Fuente: www.ismp.org/

Fecha: 10/15/21