Ensuring safer practice with Repevax and Revaxis vaccines

This Safer Practice Notice alerts health professionals to changes made to the packaging of the Repevax® vaccine in 2005. This was to distinguish it more clearly from Revaxis®.

Repevax® is recommended for pre-school boosting. Revaxis® is recommended for teenage boosting.

Prior to this change, a number of patient safety incidents and near misses involving Repevax and Revaxis vaccines were reported to the National Reporting and Learning Service. Staff had mistakenly given patients the wrong vaccine because the products had similar names, labelling and packaging. In one report, 93 school children were vaccinated with Repevax instead of Revaxis.

Sanofi Pasteur MSD redesigned Repevax packaging to help distinguish it more clearly from Revaxis. Stocks with this new packaging were distributed during the second half of 2005.

NHS organisations were advised to :

• Ensure procedures exist to check the correct vaccine has been selected on each and every administration.
• Raise awareness of the proposed changes to the packaging with all staff involved in childhood immunisations.
• Review procedures for risk assessment and management of new vaccine products introduced locally, and strengthen procedures where necessary.
• Continue to report any patient safety incidents.

This notice is an example of where mis-selection can occur due to lookalike packaging and design and soundalike product names.