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News Release

ISMP Warns about Mix-Ups between Flu Vaccine and COVID-19 Vaccines

Since the 2021-2022 influenza (flu) vaccine became available in September, the Institute for Safe Medication Practices (ISMP) has received multiple reports of mix-ups. Some patients have consented to a flu vaccine but received one of the COVID-19 vaccines instead, while others have received the flue vaccine instead of the intended COVID vaccine.

Causative factors may include increased demand and co-administration of the vaccines. The Centers for Disease Control and Prevention (CDC) has stated that both the flu and COVID vaccines can be administered during the same visit and encouraged providers to offer both to increase the probability that patients will become fully vaccinated. In addition, the Food and Drug Administration (FDA) has recommended a third COVID vaccine dose for eligible immunocompromised patients and approved a Pfizer-BioNTech COVID vaccine booster.

The October 7, 2021 issue of the ISMP Medication Safety Alert!® Acute Care newsletter details several cases reported by healthcare consumers who received the wrong vaccine and outlines other possible causative factors, including syringes for different vaccines being stored next to each other, unlabeled vaccine syringes, distractions during administration in busy pharmacies, and staffing shortages.

ISMP recommends several safety strategies for healthcare organizations to avoid mix-ups during the vaccination process. Providing adequate staffing support and scheduling vaccinations for a dedicated block of time each day where practitioners are not also dispensing regular medications can help reduce the chance of errors. Other recommendations include using barcode scanning during vaccine preparation and labeling, using manufacturer prefilled syringes of flu vaccine, and involving the patient in the checking process to verify which vaccine they are receiving.

It is mandatory to report errors with COVID-19 vaccines available under Emergency Use Authorization (EUA) to the CDC and FDA’s Vaccine Adverse Event Reporting System (VAERS). ISMP also asks providers to report vaccine errors to the ISMP National Vaccine Errors Reporting Program (VERP). For a copy of the full ISMP newsletter article with case descriptions and recommendations, click here.


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