What are the Joint Commission's expectations for managing multi-dose vials of vaccines ?

Any examples are for illustrative purposes only.

Storage and Expiration Dating:
Vaccines are exempt from the 28-day requirement. The CDC Immunization Program states that vaccines are to be discarded per the manufacturer's expiration date. The Joint Commission  applies this approach to all vaccines - whether a part of the CDC or state immunization program or purchased by healthcare facilities - with the expectation that vaccines are managed in accordance with the product manufacturer's instructions for use (correct temperature,  frequency of temperature checks, etc.) and any applicable regulatory requirements.

IMPORTANT: If you are a Vaccine for Children (VFC) provider or receive other vaccines purchased with public funds, consult your state or local immunization program  to ensure you are meeting all mandatory storage and handling requirements that are specific or tailored to your jurisdiction

Preparation:
The setting in which vaccines are prepared and administered should have adequate space to prepare a vaccine using aseptic technique to prevent vial contamination.  Consider the following: 

• There is clear physical separation of the medication storage / preparation area from the administration area.  A barrier, such as a wall, etc., is NOT required. 
• The multi-dose vaccine vial remains in the medication preparation area and does not cross into the patient administration area. 
• Any item taken into the administration area (e.g. needle, syringe, medication vial, band-aid, etc.) does not return to the medication storage/preparation area.  
• Staff utilizing the room have been trained on procedures required to prevent cross contamination.  
• All vaccination and administration supplies are secured or under constant visual surveillance to ensure cross contamination does not occur.

Influenza and Pneumococcal Vaccines: 
Unless your state is more specific, these two vaccines are not required to have a physician's order in the medical record as long as the following conditions are met:

• 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.
• There must be an evidence-based evaluation of the patient to ensure that no contraindications exist preventing the patient from the receiving the vaccine.
• 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 Statement (VIS) given to the patient. 

If all criteria are met and an order would not be required, then pharmacy would not be required to review.

• The vaccine manufacturer 
• The lot number of the vaccine 
• The date the vaccine is administered 
• The name, office address, and title of the healthcare provider administering the vaccine 
• The Vaccine Information Statement (VIS) edition date located in the lower right corner on the back of the VIS. When administering combination vaccines, all applicable VISs should be given and the individual VIS edition dates recorded. 
• The date the VIS is given to the patient, parent, or guardian. 

Resources:
Center for Disease Control (CDC)
CDC Vaccination Resources