The Pharmaceutical Services Negotiating Committee (PSNC) has recently reminded pharmacy contractors that flu vaccines must be carefully checked to ensure they are reaching the correct patient group.
So, what if you have given the vaccine to the wrong patient group? How could patients be notified and what would happen next?
"If a contractor discovers the wrong dose has been given, the patient must be informed as soon as possible," Nahim Khan, a portfolio pharmacist based in Warrington and someone who regularly oversees the administration of flu vaccines says.
Pharmacists must inform the patient, first of all "by contacting them and finding out if they’re OK, and informing them of the situation", Mr Khan adds.
"The thing with the flu vaccination is you have to do it from a risk-benefit point of view."
Read more: ‘Fantastic’ uptake: Number of pharmacy flu jabs edges closer to 1m mark
Who is the patient?
"If you were giving the one intended for over 65s to under 65s then there’s not really much of a problem. They might get a bigger immune response but you still need to inform them," Mr Khan says.
"But when you give the opposite, it becomes more of a problem and you need to do a risk-benefit assessment where you look at the individual patient and think 'Do they need another vaccination of the right vaccine'?" Mr Khan adds.
"Or if you talk to them, [you could ask if] they are OK with having the wrong one."
"But it’s a difficult process because there are so many issues involved. It could be someone who’s 69 and they’ve got asthma or some other health condition so you might think doing another vaccination is important. The processes might be different for each pharmacy," Mr Khan goes on to say.
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Reporting incidents
"A big multi-pharmacy would have a protocol to follow but you need to do an incident report which might then trigger automatically contacting the local NHS commissioning body," Mr Khan notes.
"The one for 65 and over has a special ingredient because at that age the immune system ages and doesn’t work as well as when they were younger. This extra ingredient allows the over 65s to get adequate response compared to someone who’s younger.
"That’s why we give this different vaccine for 65s and over," Mr Khan says.
How mistakes can happen
So with these guidelines in mind, how are the wrong vaccines sometimes given to patients in the first place?
"These mistakes can happen in various ways – it could be that the injector has picked the wrong one from the fridge. Although, you should always get a second check when you pick it up from the fridge," Mr Khan says.
"You have a consent form to fill in and the patient fills out their details," Mr Khan adds.
"But it’s more to do with what’s going on that particular day rather than a training or educational need."
Winter workloads
"Pharmacists are doing all the stuff they’d normally do in a day and then when winter comes they’re doing all this extra work on top of everything else," Mr Khan says.
"Winter is a busy time with an increased prescription load. Everyone’s just busy and people are off ill as well.
"PSNC says ‘Have a poster or a reminder where you’re vaccinating’, and they’re just reminding us all to take time to check," Mr Khan says.
Surprise announcement
"I was quite surprised" by PSNC's announcement, Olivier Picard, owner of Newdays Pharmacy and a member of the National Pharmacy Association says.
His four pharmacies as well as an offsite vaccination centre "have done flu vaccinations in their thousands at around 1,000 per pharmacy per season".
"This doubles when our off-site vaccination centre is factored in.
"And the reason I was quite surprised is that pharmacists are used to dispensing thousands of different medicines each day and they don’t make mistakes that often, let alone having the choice between three vaccines and giving it to the wrong person," Mr Picard adds.
Responding to the guidance
"But clearly if the guidance has come out there must have been some incidences reported and some people pointing the finger at some community pharmacists for not giving the right vaccines," Mr Picard says.
"What I suspect happens more often than not is the wrong vaccine is selected on the point of care system, as opposed to injecting in a patient’s arm," Mr Picard suggests.
So, if you have an aQIV for over 65s and a QIVc for under 65s and another for back up, or QIVe and you could click on the wrong vaccine, does that mean the patient has had the wrong one?
"Probably not – but what it means is that on paper they have," Mr Picard says.
Investigation results
"Now we didn’t have any discrepancies in my pharmacies but that would be one way of pharmacies finding out whether any record had been registered incorrectly for patients," Mr Picard notes.
"But they’re not necessarily in the same order between pharmacies, so if a pharmacist or locum worked across multiple pharmacies the way it presents itself to the pharmacist may be different.
"And one could argue that’s a good thing because it allows you to pay more attention," Mr Picard says.
Determining the patient's age
"The other thing that we do at Newdays when vaccinating is we ask for the date of birth and we also ask people to tell us how old they are," Mr Picard says.
"I know that sounds a little old fashioned but if someone is 65 or turning 66 in your head you think 'I need to give the over 65 vaccine'. The problem is when someone is 65 before March 2023 – you could potentially give someone who is 64 today but 65 in January the wrong dose."
"That person would technically need an over-65 vaccine," he says.
"If the wrong vaccine is given with the report that you run you can then find the patient. Once you’ve got the patient, you can inform the surgery and call the patient and explain the situation."
Additional vaccines
"I’m not sure whether the guidance is to administer another flu vaccine. But it was an interesting exercise to do to see if there had been any errors," Mr Picard says. "For PSNC to come up with the guidance there must have been some errors reported."
Mr Khan says systems are in place so that "it is flagged up if a patient might need a top up vaccine".
"When you input the information about the patient onto how you inform the NHS that you’ve given a vaccine it might pop up or they could have had a vaccination done and this is the second one – that can happen," Mr Khan adds.
According to PSNC the aQIV (adjuvanted Quadrivalent Influenza Vaccine Seqirus) or the QIVr or QIVc are the correct vaccines to give to patients over 65.
The aQIV is recommended 'off-label' to 64-year-olds turning 65 before 31 March 2023.
At-risk adults aged 18 to 64 - including pregnant women - should be offered QIVc (cell-based quadrivalent influenza vaccine), QIVr or QIVe.
For 50-64-year-olds not at clinical risk, it’s advised that the QIVe or QIVc/QIVr vaccines are given.
What other remedial options are available?
"It only pops up after in the system so it depends on the locality," Mr Khan says.
"PSNC has covered what to do if the wrong vaccine is given to a patient and has said it advises any patient in this situation is recalled and that a risk assessment is done to consider re-vaccinating," Mr Khan adds.
"They also recommend contacting your local NHS England screening and immunisation team for advice," Mr Khan goes on to say.
"Their website also says contractors are encouraged to review their clinical practice to ensure their vaccination provisions are in line with the appropriate guidance and any risk of inappropriate vaccination has been considered and the risks mitigated," Mr Khan concludes.
Cause for concerns
PSNC has been told of cases where the QIVe flu vaccine has been given to over 65s when there is no provision for use of this vaccine in that patient group after the Joint Committee on Vaccination and Immunisation said it was not effective for patients over 65.
If QIVe has been given to anyone aged 65 years or over, the available
guidance advises that the patient is recalled and a risk assessment undertaken to consider re-vaccinating with an appropriate vaccine for their age group.
