Vaccine Administration Error
A 16-year-old girl comes to the pharmacy for a routine HPV vaccine. The pharmacy administers the first dose of the HPV vaccine series. The protocol requires the vaccine to be administered intramuscularly in the deltoid. However, the technician accidentally administers the vaccine subcutaneously in the fatty tissue of the upper arm. The patient is fine and has no immediate reaction. The pharmacist is informed after the fact. The pharmacy's policy requires reporting of all administration errors. The patient's mother is present and asks if the dose is still valid.
1. Is the dose valid? What should be done?
Read the worked answer
The dose is not valid because the HPV vaccine is intended for intramuscular administration. Subcutaneous administration may result in a suboptimal immune response. According to CDC guidelines, doses administered by the wrong route should be repeated. The repeat dose should be administered at least 4 weeks after the invalid dose (or as recommended by the manufacturer). The patient should be informed and the dose repeated intramuscularly. The incident should be documented and reported through the pharmacy's error reporting system. The patient's mother should be reassured that the error is being addressed and that the repeat dose will be given correctly.
2. What documentation and reporting are required?
Read the worked answer
Document the following:
- Patient information: Name, DOB, date of vaccination.
- Vaccine details: HPV vaccine, lot number, dose, expiration date.
- Error details: Incorrect route (subcutaneous instead of intramuscular), site, and time.
- Personnel involved: Technician who administered, pharmacist who supervised.
- Patient response: No immediate reaction.
- Corrective action: Repeat dose to be given intramuscularly after appropriate interval; patient and mother counseled.
- Reporting: Complete an internal incident report as per pharmacy policy. Report to the Vaccine Adverse Event Reporting System (VAERS) if an adverse event occurs; administration errors may also be reported to the Institute for Safe Medication Practices (ISMP) or other error reporting systems. Notify the primary care provider if appropriate.
- Follow-up: Ensure the repeat dose is scheduled and administered correctly. Document the repeat dose.