Received Jul 30, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| VARZOS | ZOSTER (SHINGRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | — | — |
administration of only the adjuvant; administration of only the adjuvant; This non-serious case was reported by a pharmacist via call center representative and described the occurrence of inappropriate preparation of medication in a patient who received Herpes zoster (Shingrix) for prophylaxis. In JUN-2025, the patient received Shingrix. In JUN-2025, an unknown time after receiving Shingrix, the patient experienced inappropriate preparation of medication (Verbatim: administration of only the adjuvant) and inappropriate dose of vaccine administered (Verbatim: administration of only the adjuvant). The outcome of the inappropriate preparation of medication and inappropriate dose of vaccine administered were not applicable. Additional Information: GSK receipt date: 15-JUL-2025 Reporter stated that they have had several reports of the Shingrix vaccine being administered incorrectly across their organization. Often times, the nurse was giving the patient the adjuvant vial and not reconstituting prior with the adjuvant. The issue was being caused by the way the product was stocked in their medication dispensing cabinets. Because the 10-count box were purchased, the vials were loaded into the cabinet and box discarded, therefore nursing does not had the barcode to be able to scan. Given the structure of the records in their EHR, the barcodes on the individual vials do not scan because the system was expecting the barcode on the outer kit. Because of this, nursing can't scan anything, contributing to them just scanning the adjuvant vial and administering that thinking it's the whole product (they have to bypass the scan so are not getting any sort of trigger that they need to scan the correct vials). The patient received only adjuvant of Shingrix, which led to inappropriate preparation of medication and inappropriate dose of vaccine administered.