Received Mar 25, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| HEPA | HEP A (HAVRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | UNK | — |
| VARZOS | ZOSTER (SHINGRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | UNK | — |
design/colorway is very similar to the peds Hep A carton; design/colorway is very similar to the peds Hep A carton which could increase the risk of vaccine administration errors; This non-serious case was reported by a consumer and described the occurrence of product packaging confusion in a patient who did not receive Herpes zoster (Shingrix) for prophylaxis. Co-suspect products included HAV (Havrix) for prophylaxis. The patient did not receive Shingrix and Havrix. The patient experienced product packaging confusion (Verbatim: design/colorway is very similar to the peds Hep A carton) and circumstance or information capable of leading to medication error (Verbatim: design/colorway is very similar to the peds Hep A carton which could increase the risk of vaccine administration errors). The outcome of the product packaging confusion and circumstance or information capable of leading to medication error were not applicable. This report is made by GSK without prejudice and does not imply any admission or liability for the incident or its consequences. Additional Information: GSK Receipt Date: 13-FEB-2026 The customer reported that the colors used for the packaging were almost identical, which led them to place sticky notes on the Shingrix boxes to prevent it from being mistaken for Havrix. Although no medication errors had occurred yet, a few Shingrix doses had been accidentally pulled out but were identified before administration. The customer mentioned that the Shingrix packaging was confusing due to its resemblance to the Havrix packaging. This issue had potentially been escalated previously. A nursing director expressed concern regarding the packaging of Shingrix. She had been asked if she had ordered the Shingrix prefilled syringes, and she confirmed that she had and shared her dislike for the box design, noting its similarity to the Hepatitis A packaging. She showed the fridge where Shingrix and Hepatitis A vaccines were stored and pointed out that she had circled the Shingrix label with a red marker to make it more noticeable. She was worried about the risk of mistakenly grabbing the wrong box. The customer also noted that a shipment of new Shingrix prefilled syringes had arrived that day. While they appreciated the prefilled syringes, they were concerned that the box was the same red color as the pediatric Hepatitis A packaging. They suggested other offices should be informed of this issue if they had not yet received their doses. The customer stated they would work on implementing safety measures to ensure the two vaccines were stored separately in their office to prevent potential errors.