ABCDEFGHIJKLMNOPQRSTUV
1
Process Decision Program Chart For COVID-19 Vaccine Waste (Working Document - Created January 15, 2021)
2
3
Potential Causes of Vaccine Waste
Probability of Occurrence
Potential CountermeasuresAdditional Notes
4
Note if applicable to Pfizer, Moderna, Both
High, Medium, or LowPfizer, Moderna, Both
5
Probabilities should be assessed by individual sites
6
Please Add Potential Causes to this List by Using the Comment FunctionPlease Add Countermeasures to this List by Using the Comment Function
7
Spoiled - BSchedule vaccine delivery when appropriately trained staff are guaranteed to be present during a full day receiving hours. - B
8
In motor vehicle with defrosted vials stuck in the snow - go car to car to other stuck vehicles and flag down motorists to get vaccine into their arms - BAdded January 30, 2021 - This event occured in Josephine, OR
9
10
Clinic/Pharmacy closing and there are frozen doses left over - BIf vaccine is thawed and reaching expiration or vials have been opened and there are too few individuals in the target group to be vaccinated, immediately recruit/seek other potential vaccine recipients. This may be necessary as a clinic/pharmacy is closing and has unfrozen vaccine remaining. Develop a call list. - B
11
12
Lost - BStaff member should track product daily until arrival. Guidance should be developed regarding tracking parameters, i.e., after 3-5 days contact vendor. - B
13
14
Expired - BDetermine demand for vaccine to prevent excessive ordering using target population data. Consider staffing and other logistics capacity to give vaccine in timeframe of product storage and shelf life. - B
15
16
Refrigerator/Freezer Problems - BInstall/test alarms, auto calls, backup generator. - B
17
Establish arrangements in advance with other clinics/jurisdictions that can serve as back-up in the event there are refrigeration problems. - B
18
Use social media to spread the word in the event of refrigerator/freezer failure - BAdded January 30, 2021 -- UW Medical Center employed this strategy when freezer failed at 11:00pm.
19
20
Damaged Vials - MImmediately examine shipment for signs of damage. Vials should be stored in the original carton and protected from light. Call the phone number indicated in the instructions or your jurisdiction's immunization program if there are damaged vials. - M
21
Damaged Vials - PInitially, keep the trays closed and inspect only the outside of the package and trays. If you have concerns about the condition of the package, contact the manufacturer. Inspect vials when you are ready to thaw and use the vaccine. - P
22
23
Contaminated - BImmediately contact vendor/manufacturer if contamination is identified or suspected. Should have accurate inventory system to determine if contaminated vials have been used. Contact those who received doses from contaminated vials. Separate contaminated product and clearly label "DO NOT USE." - B
24
25
Mislabeled - BDevelop and follow guidance for daily/weekly inventory check to ensure errors are found. New delivery should be checked within 24 hours. Develop prepared labels. - B
26
27
Power Failure - BHave back-up generator to come on during power outage. Follow manufacturer guidance. Develop and follow emergency vaccine storage measures for power outage if no generator. - B
28
29
Backup Generator Fails - BImplement emergency vaccine storage protocols. Consider what is needed to maintain manufacturer required temperatures. - B
30
31
Not Put in Refrigerator - BDevelop step-by-step instructions for receiving vaccine shipments; can be a checklist. - B
32
33
Freezer can't reach ultra cold temps - PMust be able to vaccinate within shelf life parameters. - P
34
35
Temperature alarm failed - BAlarm should be checked consistently on a weekly basis. - B
36
37
Unable to extract all vaccine from vial - PAcquire low dead space syringes (in short supply -- look for opportunities to preorder) - PAdded January 23, 2021 - Reported in Washington Post
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100