By Ambika Sharma, Heidi Huang, Shabina Rangarej, Dorothy Tscheng, and Alice Watt

Canada’s mass COVID-19 vaccination clinics have represented a historic mobilization of resources and expertise to inoculate record numbers of Canadians. The numbers are impressive; for example, a single vaccination site in Toronto administered more than 26 000 doses in a single day. These accomplishments are undeniably a feat worth celebrating, yet with vaccine doses being administered in such large numbers, it was likely that some errors would occur. In this regard, the Institute for Safe Mediation Practices Canada (ISMP Canada), a nonprofit organization committed to the advancement of medication safety in Canada, has received reports of adult COVID-19 vaccines being inadvertently administered to children eligible for the pediatric dose.

In light of these concerns, hospital- and community-based clinics have been developing effective strategies to systematically prevent confusion between pediatric and adult vaccine doses. For example, the Michael Garron Hospital in Toronto, Ontario, which hosted several mass vaccination clinics, created clear, segregated processes for pediatric and adult dose preparation, patient registration, and dose administration. Throughout the vaccination process, the hospital consistently used a distinctive colour (green) to differentiate pediatric vaccine doses from adult doses (Figure 1). Designated staff prepared only pediatric doses in green-labelled syringes and stored those vaccines in foam coolers marked with green labels. Upon patients’ arrival, staff gave children in the eligible age group green wristbands to signify that they would need a pediatric dose. Those patients were then led toward the pediatric vaccination stream, where selected staff administered only pediatric doses in a distinct area clearly marked with green signs. Furthermore, dedicated site leads independently double-checked each pediatric patient’s eligibility before administering the vaccine.

Along with clear check processes and specific staff assigned to administer pediatric doses, colour differentiation is one effective way to provide simple visual cues at a clinic. When consistently implemented at each step in the vaccination process, such strategies reduce the risk of vaccine dosing errors. These techniques and lessons learned, applied here in the context of a mass vaccination clinic, are also suitable for use in other health systems to enhance medication safety.

Acknowledgement: ISMP Canada extends appreciation to Michael Garron Hospital for allowing details of its organizational actions to be shared, with the goal of preventing COVID-19 vaccine dosing errors in children eligible for the pediatric dose.

Ambika Sharma, RPh, PharmD, BScPhm, HBSc, is a Senior Medication Safety Specialist at ISMP Canada, a Course Coordinator at the University of Toronto’s Leslie Dan Faculty of Pharmacy, and a community pharmacist in a compounding pharmacy.

Heidi Huang, RPh, BScPhm, is a pharmacy Vaccine Lead at Michael Garron Hospital.

Shabina Rangarej, RN BScN, MN, is Clinical Operations Manager for the COVID-19 vaccine clinics at Michael Garron Hospital (MGH).

Dorothy Tscheng, RPh, BScPhm, CGP is the Director of Practitioner & Consumer Reporting & Learning overseeing the analysis and knowledge translation outputs from these programs.

Alice Watt RPH, BScPhm is a Senior Medication Safety Specialist at ISMP Canada and a hospital pharmacist at a community hospital.