1/ I’m seeing so many photos of unlabelled pre-prepared syringes in all sorts of locations. It’s freaking this pharmacist out! Please consider labelling them and getting clean transport containers. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i2-COVID19-Vaccine-Error-Prevention.pdf

2/ Our clinic works with Pfizer which means we have a diluent and a higher risk of error. We have a diluter, a person preparing doses, and then a pharmacist who does a final check and labels everything. We colour code for expiry.

3/ You can see the story here about the people mistakenly being injected with diluent—each site has their own flow and best practices and we’re learning from each other (and each other’s mistakes). https://www.thestar.com/local-vaughan/news/2021/04/19/vaughan-covid-19-vaccine-clinic-mistakenly-injects-saline-instead-of-pfizer-doses.html

4/ Mistakes happen. All sorts. The goal is to build systems that prevent errors or catch all errors before they reach the patient. Here’s an excellent list of different COVID vaccine errors and how to handle each one from the US CDC. https://www.cdc.gov/vaccines/covid-19/downloads/covid19-vaccine-errors-deviations.pdf

5/ Pharmacies and primary care sites likely have multiple vaccines and injectable drugs on site. A double-check/label marks the time and ensures the person drawing up the dose chose the right vial. The double check is also a good time to check for the correct volume and bubbles.

6/ Beyond errors you have infection prevention and control. Even for vaccines that don’t need reconstitution, the doses should be used as soon as possible after being drawn up (ideally <1h). These vaccines are preservative free. We don’t want to inject with the vaccine.

7/ For vaccines being transported, ideally the dose will be drawn up immediately before injection. If not it should be labelled and transported in a clean container. Not a stuffed in a pocket or a car console. Use the best asceptic technique you got.

8/ This is a pandemic, I totally get it. There is a form of field medicine that is needed to reach everyone. Still, there are little things that can be done to prevent errors and minimize infections.