ACP participated in a review of an article published by the Institute for Safe Medication Practices (ISMP) Canada, which analyzed several reports describing administration of an incorrect respiratory syncytial virus (RSV) immunizing agent to patients. Reports included descriptions of infants receiving an adult vaccine, pregnant persons receiving the incorrect adult vaccine, and inadvertent substitutions with other vaccines. ACP is aware of similar incidents occurring in Alberta.
Key contributing factors to the practice incidents included lack of familiarity with the numerous new RSV immunizing agents, poor design of vaccine storage areas, and lack of labelling of pre-drawn syringes.
The ISMP Canada article includes recommendations to inform continuous quality improvement activities that support safe administration of the right product to the right patient. ACP is sharing this article with regulated members so that they may avoid similar incidents in their pharmacy.
