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Audio and Web Conference

Video | Safely Maximizing COVID-19 Vaccine Dosing–Clarifying Syringes and More

View a recording of our March 17, 2021, live-streamed lab webcast. At the end of this webinar, attendees will be able to:

  • Adhere to key steps for safe and efficient syringe handling during vaccine preparation and administration
  • Understand information about error reporting
  • Prepare for changes in the upcoming months in terms of necessary supplies

The presentation concludes with an informative Q&A session based on questions from hospitals around the globe.


  • Dr. Andrew Furman, Executive Director, Clinical Excellence, ECRI
  • Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, President, ISMP
  • Kevin N. Hansen, PharmD, MS, BCPS, Assistant Director of Pharmacy, Moses H. Cone Memorial Hospital
  • Jason Launders, Director of Operations, Device Evaluation, ECRI
  • Kristina Cybularz, Manager, Supply Guide—Supply Chain Services, ECRI
  • Juuso Leinonen, Senior Project Officer, Device Evaluation, ECRI

Lab tour recording

Supplementary materials

Key Takeaways

Reported COVID-19 vaccine errors

The Institute for Safe Medication Practices (ISMP) encourages facilities to report vaccine errors to its voluntary error reporting system. Reported errors include the following:

  • Dilution errors leading to under- or overdose of vaccine
  • Mixing errors with two-component vaccines (diluent instead of vaccine or wrong diluent such as sterile water)
  • Air injected into vial instead of diluent
  • Storage issues (unsegregated vaccine brands in refrigerator)
  • Wrong vaccine given for dose 2 (not checking/documenting in immunization information system)
  • Administration to wrong age group
  • Waste of vaccine and not taking advantage of over-fill in vaccine vials
  • Errors in scheduling second dose
  • Look-alike vials (vaccine-monoclonal antibody mix-up)
  • Shoulder injury related to vaccine administration (SIRVA)

Preventing errors with COVID-19 vaccines

  • Verify competency of preparers and vaccinators (many are volunteers)
  • Dispense pharmacy-prepared and labeled syringes when possible, or one person prepares and administers
  • For mass vaccination, utilize a standard, organized process with independent double checks
  • Maximize doses withdrawn from vials
  • Separate vaccines in storage
  • Plan for leftover vaccine
  • Be prepared for allergic reactions
  • Report vaccine errors and adverse reactions (U.S. requires reporting to VAERS); additional reporting to ISMP is voluntary
  • Utilize immunization information systems

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Additional resources

American Society of Health-System Pharmacists, Institute For Safe Medication Practices, U.S. Pharmacopeia: FAQ for Optimizing COVID-19 Vaccine Preparation and Safety

ECRI is here to help

Our interdisciplinary staff is here to help you address your most challenging issues in your response to COVID-19. We have compiled free resources in the ECRI COVID-19 Resource Center. Please contact us for assistance and to learn more. 

Return to the ECRI COVID-19 Resource Center

* All material in this COVID-19 Resource Center,, is protected by copyright, and all rights are reserved under international and Pan-American copyright conventions. However, in light of current circumstances, due to the COVID-19 pandemic, ECRI will permit the ECRI content accessible from this COVID-19 Resource Center to be reproduced and shared, in whole or in part, for non-commercial purposes only. If you desire to reproduce or share content from third-party sources cited within this Center, you must first seek approval from that third-party source.


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About ISMP

Click to learn about the Institute for Safe Medication Practices.