This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate.
PRIORIX® is a measles, mumps, and rubella vaccine manufactured by GSK. It is available in cartons containing 10 single-dose vials of lyophilized antigen component and 10 single-dose prefilled ungraduated syringes of sterile water diluent. The prefilled diluent syringes have luer tips to accommodate the attachment of needles to reconstitute the vials of lyophilized antigen and to administer the vaccine. Recently, a patient arrived at a clinic for the vaccine. It was a busy day in the clinic, and when the nurse went to retrieve and prepare the PRIORIX vaccine, they only removed a syringe of sterile water from the carton, leaving the vial of lyophilized antigen in the carton. They reported they did not see the vial containing the lyophilized antigen, as it was “hidden” by the inside flap of the carton. The nurse administered the diluent alone and did not uncover the error until finding an extra vial of lyophilized antigen in the carton a couple of hours later.
To prevent preparation and administration errors with vaccines that come with prefilled diluent syringes, ISMP recommends establishing a process to keep vaccines and their corresponding diluents together, if storage requirements do not differ. Implement barcode scanning prior to preparing and administering vaccines. Configure the system to require scanning of both the vaccine and corresponding diluent barcodes. Provide vaccine-specific auxiliary labels to facilitate relabeling of the diluent syringe after the vaccine is reconstituted and withdrawn from the vial. Store the labels with the specific vaccine products. Document the National Drug Code number, lot number, and expiration date of each container in the vaccination record or log before administration to confirm the appropriate selection or preparation of both components. Documenting the actual administration of the vaccine should always occur after the vaccine is administered.