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Vaccine Administration - Orders and Pharmacy Review

What are the requirements regarding orders and pharmacy review prior to vaccine administration ?

Any examples are for illustrative purposes only.

Influenza and Pneumococcal Vaccines: 

Unless your state is more specific, these vaccines are not required to have a physician’s order in the medical record as long as certain conditions are met which are listed below:
1. There must be a hospital policy and procedure approved by the medical staff which allows Influenza and Pneumococcal Vaccines to be given without a physician’s order.
2. There must be an evidence-based evaluation of the patient to ensure that no contraindications exist preventing the patient from the receiving the vaccine.
3. The medical record must contain evidence of the vaccination administration to include the Manufacturer Lot # and Expiration Date as well as the publication date of the vaccine information sheet (VIS) given to the patient. 
4. If all of these criteria are met, since an order would not be required then pharmacy would not be required to review.

For all Vaccines except Influenza and Pneumococcal Vaccines:

Since vaccines are considered medications, they are subject to the requirements found in the Medication Management (MM) chapter of the accreditation manual.  Please note that MM.05.01.01 EP 1 states Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication".

Regarding patient-specific orders and pharmacy review, there are a number of states that allow vaccines to be administered based on a standing order that can be implemented when a patient meets certain pre-defined criteria (age, medical condition, etc), thus eliminating the need for an individual physician order.  Your organization would need to determine if their state permits the use of such standing orders for vaccine administration as you describe.  However, a pharmacist will still need to review this standing order in regards to the particular patient in which it was ordered for evaluation of contraindications, etc.

Please note that while our standards do not address issues related to payor source, when patients are covered under entitlement programs, such as Medicare, an order to implement a protocol may be required to be entered into the medical record.  Again, your organization should research this within their state.  Regardless of the payor source, to ensure compliance with RC.02.01.01, a copy of the standing order/protocol etc., should be included in the medical record.

Last updated on January 11, 2021
Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM

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