Mix-ups Between the Influenza (Flu) Vaccine and Coronavirus Disease 2019 (COVID-19) Vaccines

 

The 2021-2022 influenza (flu) vaccine became available in September 2021. Since then, the Institute for Safe Medication Practices (ISMP) has received numerous reports of mix-ups between the flu vaccine and coronavirus disease 2019 (COVID-19) vaccines. Most of the reports were from consumers. All of the mixups occurred in retail pharmacies. In most cases, people went to their local pharmacy for a flu vaccine but received one of the COVID-19 vaccines instead. But in a few cases, people received the flu vaccine instead of the intended COVID-19 vaccine. Here are a few examples of the errors that were reported.

 A 23-year-old woman received the Pfizer-BioNTech COVID-19 vaccine instead of the flu vaccine. The mistake was noticed after the COVID-19 vaccine was given and the pharmacist asked the woman when she received the first two COVID-19 vaccines. The pharmacist apologized for the mistake and just documented “COVID (3rd)” in the paperwork that was given to her.

A 26-year-old man made an appointment at a local pharmacy for the flu vaccine. Upon arrival, he was given a questionnaire with a consent form and a leaflet about the flu vaccine. However, he was accidentally given a COVID-19 vaccine. The error was immediately discovered, and the man was given the requested flu vaccine. However, the pharmacy provider never gave the man a record of the third COVID-19 vaccine given in error.

A mother, son (10 years old), and daughter (6 years old) received the Moderna COVID-19 vaccine instead of the flu vaccine. When the mother began having symptoms similar to those she had after receiving previous doses of the COVID-19 vaccines, she called the pharmacist. After watching a video of the vaccination clinic, the pharmacist called the mother to report that she had received the Moderna COVID-19 vaccine in error. The pharmacist assured the mother that her children had received the flu vaccine. But after her daughter developed a skin reaction on her arm at the vaccination site, the mother called the pharmacist and asked him to watch the video again. A few days later, the pharmacist called the mother to say that both of her children had also received the COVID-19 vaccine instead of the flu vaccine.

A 70-year-old man received the Pfizer COVID-19 vaccine instead of the flu vaccine. He filled out a questionnaire and consent form for the flu vaccine. After the vaccine was given, the pharmacy provider told him that he now had his “COVID-19 booster.” He was then given the correct flu vaccine and was asked to provide consent for the COVID-19 vaccine he had received in error.

A 22-year-old man was scheduled to receive his first COVID-19 vaccine dose. The pharmacy provider assumed he was there to receive the flu vaccine and administered that instead. About 20 minutes after the man left the pharmacy, he received a call about the error. It is unclear if the man returned to the pharmacy to receive the COVID-19 vaccine.

A 21-year-old woman was scheduled to receive a COVID-19 vaccine but was given the flu vaccine instead. Before the error was recognized, the woman had been given a COVID-19 vaccination card.The woman later noticed that the forms she had received from the pharmacy suggested that she had received the flu vaccine, rather than the COVID-19 vaccine. She returned to the pharmacy, where the error was confirmed. The woman received her COVID-19 vaccine but no apology for the error.

Some of the possible causes of these vaccine mix-ups include the following:


Increased demand. Flu season (September to January) is already a busy vaccination time for local pharmacies. In fact, pharmacies can barely keep up with the vaccination demand, especially with approval of COVID-19 vaccine boosters for certain groups, and those still needing and requesting a first and second COVID-19 vaccination.

• Both vaccines during same visit. The Centers for Disease Control and Prevention (CDC) recommends that healthcare providers offer both the flu and COVID-19 vaccines during the same visit (www.ismp.org/ext/784). However, this may contribute to mix-ups between the two vaccines.

• Vaccine syringes near each other. Two pharmacy providers, who mistakenly picked up a COVID-19 vaccine syringe instead of the flu vaccine syringe, said the two vaccine syringes were located next to each other in the vaccination area. Bringing both vaccines into a patient vaccination area when they are not needed sets the pharmacy provider up for a possible mix-up.

• Unlabeled syringes. The flu vaccine often comes in ready-to-give syringes that are labeled. However, COVID-19 vaccines come in vials containing many doses and must be prepared in a syringe for each patient. It is possible that the COVID-19 vaccine syringes were not labeled, increasing the risk of a mix-up.

• Distractions. After a vaccine mix-up, one pharmacy provider told a woman that he had become distracted by their conversation. Interruptions and other distractions in a busy pharmacy could also lead to mix-ups.

• Staffing shortages. Because many pharmacies are facing staffing shortages, it is possible that vaccine providers are multi-tasking and are hurried or rushed. For example, a pharmacist who was working alone in a busy pharmacy recently told us that she gave more than 50 vaccinations during her shift, in addition to dispensing prescriptions.

To help avoid mix-ups between the flu and COVID-19 vaccines, follow the recommendations below when visiting the pharmacy:

• Identify yourself. Provide your full name and date of birth to the pharmacy provider when you approach the pharmacy counter, and right before you receive the vaccine(s).

 Identify the vaccine(s) you want. Say aloud which vaccine(s)you want to receive. When asked to complete a questionnaire and sign a consent form(s)for the vaccine(s), make sure the form lists only the vaccine(s) you requested.

• Get involved in the checking process. Ask to see,and then read aloud, the label on the vaccine syringe and the expiration date to confirm it is the vaccine you requested. Talking with the pharmacy provider about your vaccine before it is given can reduce the risk of amix-up.

• Avoid distractions. Expect to receive your vaccine in a separate area, away from distractions and interruptions.

• Get the intended vaccine. If a mix-up occurs between the flu and COVID-19 vaccines, ask for the correct vaccine during the same visit (both can be given during the same visit), or be sure to return to the pharmacy to receive the correct vaccine.

• Get the required documentation. If a mix-up happens and you receive the COVID-19 vaccine or booster in error, ask for a record of the vaccination (date given, vaccine manufacturer, and lot number). Report any errors. If an error was made and you received the wrong vaccine, report it to the ISMP National Vaccine Errors Reporting Program (ISMP VERP, www.ismp.org/report-medication-error).

Created on January 7, 2022

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