March 2020

©2020 American Pharmacists Association and Washington State University

Pharmacy‐Based
Immunization Administration
by Pharmacy Technicians:
Live Program

Developed by Kimberly C. McKeirnan, PharmD, BCACP,

Washington State University College of Pharmacy and
Pharmaceutical Sciences

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ACPE Accreditation Information

The American Pharmacists Association is accredited by the Accreditation Council for
Pharmacy Education as a provider of continuing pharmacy education. Successful
completion of this live seminar component involves attending the full live seminar, successfully
completing the injection technique assessment and completing the online assessment and
evaluation. Successful completion of this component will result in 4 contact hours of CPE credit
(0.4 CEU).
ACPE UAN: 0202‐0000‐20‐125‐L06‐T; 0202‐0000‐20‐125‐L06‐P
Activity Type: Practice‐based
Target Audience: Technicians and Pharmacists in all practice settings
Release Date: January 20, 2020
Expiration Date: January 20, 2023
For complete ACPE information and disclosures, see the online materials

Learning Objectives
 Demonstrate appropriate technique when administering an intramuscular injection.
 Demonstrate appropriate technique when administering a subcutaneous injection.
 Recognize the role of the pharmacy technician in immunization administration.
 Demonstrate the use of universal precautions as they pertain to blood borne
pathogens.
 Recall the procedures for managing a vaccine reaction emergency.

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Acknowledgements
Advisory Board APhA Staff Members
 CHAIR: Kimberly C. McKeirnan, PharmD, BCACP  Daniel Zlott, PharmD, BCOP, Vice President,
Professional Education Resources
 Kyle Frazier, PharmD
 Kelly French, MPH, Director, Advanced Training
 Taylor Bertsch, PharmD
 Bronhed Shaw, Associate Director, Advanced
 Linda Garrelts MacLean, BPharm, RPh Training
 Lauren B. Angelo, PharmD, MBA
 Adam C. Welch, PharmD, MBA, BCACP, FAPhA
 Mitchel C. Rothholz, R.Ph, MBA

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Disclosures
 Kimberly C. McKeirnan, PharmD, BCACP, has no disclosures.
 Kyle Frazier, PharmD has no disclosures.
 Taylor Bertsch, PharmD, has no disclosures.
 Linda Garrelts MacLean, BPharm, RPh, has no disclosures.
 Lauren B. Angelo, PharmD, MBA, has served as a speaker for Seqirus, Inc.
 Adam C. Welch, PharmD, MBA, FAPhA, has no disclosures.
 Mitchel C. Rothholz, R.Ph, MBA, declares that his spouse is an employee of Merck and that he has served on
advisory boards for Merck and Pfizer
All other individuals involved in the development of this material declare no conflicts of interest or financial
interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings,
and honoraria. Every attempt has been made to ensure that the information found within this presentation is
accurate and current at the time of publication; however, standards and recommendations change regularly so
participants are advised to verify all information and data before treating patients or employing the practices
described in this educational activity. The content found in this presentation does not necessarily reflect the views
of the American Pharmacists Association or Washington State University.

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Getting to Know You

 Please share your name and current role.

 Why did you decide to participate in this training?

 Describe your previous experience with immunizations.

 Do you have any expectations/goals for this program?

Questions about the self‐study material before we begin?

Other questions?

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Review from Self‐Study: Definitions

 Immunization: A process by which a person becomes protected against a disease through vaccination;
used interchangeably with vaccination or inoculation.

 Vaccine: A product that stimulates a person's immune system to produce immunity to a specific
disease, protecting the person from that disease.

 Administer: Dispense or apply. In this case, the act of getting the vaccine ready and injecting it into
the patient.

 Route of The path by which a drug (e.g. vaccine) is brought into contact with the body (e.g. via
Administration: injection).

 Site: The physical location on the body (e.g. left deltoid or right thigh).

Review from Self‐Study: Clinical Tasks vs. Technical Tasks

Roles Performed by Technicians: Roles Performed by Pharmacists:

 Drawing up vaccine  Verifying the vaccine is appropriate for

 Preparing vaccination supplies the patient
 Administering vaccine to the patient  Verifying the prescription
 Documenting vaccination  Counseling the patient
 Answering clinical questions
 Medical decision‐making
 Responding to a medical emergency

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Safety

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Universal Precautions
 Universal Precautions: an approach to infection control to treat all human blood and
certain human body fluids as if they were known to be infectious for HIV, HBV and
other bloodborne pathogens.
 A great resource for universal precautions related to vaccination is The Pink Book
(Epidemiology and Prevention of Vaccine‐Preventable Diseases) Chapter 6: Vaccine
Administration. https://www.cdc.gov/vaccines/pubs/pinkbook/vac‐admin.html

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OSHA Bloodborne Pathogens Standard

 Require training with annual updates*
 Require use of universal precautions
 Require an exposure control plan (ECP)
 Require employer to provide hepatitis B vaccine to employees with potential risk
 Mandate use of safer devices (safety needles)
 Require documentation of safety device evaluation
 Require documentation of injuries

*OSHA requires specific training that is not included in this course

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Universal Precautions: Hand Hygiene

 Hand Hygiene means cleaning your hands by using either handwashing (washing hands
with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol‐based
hand sanitizer including foam or gel), or surgical hand antisepsis.
 Hand hygiene is critical to prevent the spread of illness and disease.
 Hand hygiene should be performed before vaccine preparation, between patients, and
any time hands become soiled.
 Hands should be cleansed with a waterless alcohol‐based hand rub or washed
thoroughly with soap and water.
 Carefully remove gloves to prevent hand contamination.

Hand Hygiene in Healthcare Settings https://www.cdc.gov/handhygiene/providers/index.html

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Universal Precautions: Gloves

 Wear gloves when it can be reasonably anticipated that contact with blood or other
potentially infectious materials could occur.
 Gloves are not a substitute for hand hygiene.
• If your task requires gloves, perform hand hygiene prior to donning gloves, before touching
the patient or the patient environment.
• Perform hand hygiene immediately after removing gloves.
 Change gloves and perform hand hygiene during patient care, if gloves become
damaged or visibly soiled with blood or body fluids following a task
 Never wear the same pair of gloves in the care of more than one patient.
 Carefully remove gloves to prevent hand contamination.

Hand Hygiene in Healthcare Settings https://www.cdc.gov/handhygiene/providers/index.html

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Universal Precautions: Needle Safety

 Take care to prevent injuries when using needles.
 Do not recap used needles after the needle has been used.
 Do not remove used needles from disposable syringes by hand; and do not bend,
break, or otherwise manipulate used needles by hand.
 Place used disposable syringes and needles in puncture‐resistant containers for
disposal.
 Locate the puncture‐resistant containers as close to the use area as is practical.

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Sharps Container
Placement of the Sharps Container:
 Always place near your dominant hand, as close as possible.
to point of use, so opening is accessible and visible.
 NEVER reach across your body to dispose of needles.
 Ensure container remains upright at all times.
 Never leave sharps containers unattended, secure containers in pharmacy when not in
use.

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Safeguarding Against Needlesticks

 Sharps container should be placed where the risk of needlesticks is minimized.
• Pharmacist should not cross his or her body to deposit the syringe in the sharps container after the injection.

 Never recap a needle after the needle has been removed from the patient.
 Never throw trash in the sharp’s container.
 Immediately place sharp into container, do NOT set it down.
 Do not share containers.
 Do not overfill containers, adhere to fill line.

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Sharps Container

Which technique is correct?

Why?

The technique in the picture on the left is better...

 Sharps is located near dominant hand.
 Sharps is within easy reach.

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Disposal of Non‐Sharp Supplies

Where is the Biohazard Bag?
• Biohazard containers keep materials separate from regular garbage.
• Use to dispose of gloves, cotton, anything exposed to patient blood
(except for needle & syringe).
• If a biohazard bag is not available, designate a garbage can for
immunization supplies (except sharps or anything exposed to
patient’s blood).

Cleanup:
• Place an absorbent pad down on the workstation and keep all
pieces of garbage contained on this to make cleanup easy.
• A paper towel may also be used if absorbent pads are not available.

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Needle Safety: Safe Techniques for Recapping

 NEVER recap a needle after it has been used.
• Okay to recap after drawing up vaccine before injecting into
patient.
 Useful methods to recap if unused:
• The scoop method – one‐handed; lay the cap on the table
and scoop up the cap with the needle. Keep the other hand
far away from the needle.
• The anchor method – put heel of palms together and
recapping to prevent arm movement.
 Your turn! Practice safe techniques to recap
needle.

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Choosing the Right Needle

• Subcutaneous: use a 23‐25 gauge, 5/8” needle
• Intramuscular: use a 23‐25 gauge, usually 1” but may vary (see
table) Needle length for intramuscular injection
Gender/Weight Needle Length
Female or male less than 130 lbs 5/8” to 1”
Female or male 130‐152 lbs 1”
Female 153‐200 lbs
1” to 1 ½”
Male 153‐260 lbs
Female 200+ lbs
1 ½”
Male 260+ lbs

• A 5/8” needle may be used for patients weighing less than 130 lbs for IM
injection in the deltoid muscle only if the subcutaneous tissue is not
bunched and the injection is made at a 90‐degree angle.

Administering Vaccines to Adults: Dose, Route, Site, and Needle Size: https://www.immunize.org/catg.d/p3084.pdf

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Time to Practice
Which needle is bigger around, a 23‐gauge needle or 25‐gauge needle?
• Answer: 23 gauge.
 Why do we use different needle lengths?
• Answer: If the needle is too long, we risk hitting the bone. If the needle is too
short, we may not be able to administer to the proper tissue.
• These are RECOMMENDATIONS, they are not absolute.
 Why would you want to use a 3mL syringe instead of a 1mL syringe? 0.5mL of
vaccine will fit in either option.
• Answer: Depressing the plunger can lead to movement of your hand, which may
cause discomfort for the patient. Having a shorter distance to move the plunger
will decrease the risk of causing the patient unnecessary pain.

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Types of Syringe Safety Devices

Shield Mechanism Retraction Mechanism

It is up to pharmacy staff to review and determine which type of device to use and be aware of how to use it safely.

See OSHA standards for more information: https://www.osha.gov/SLTC/bloodbornepathogens/standards.html

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Use of Safety Devices

• If the safety device does not activate, immediately put
the needle directly in the sharps container.
• Make sure the needle is tightly fastened to the syringe
if using a luer‐lock.
• Practice with safety devices you will be using before
you interact with a patient.
• Safety devices are intended to be activated with one
hand, do not use your other hand to activate.
• OSHA and the CDC recommend using safety devices
after use and then immediately discarding the needle
and syringe in a sharps container.

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Immunization Preparation

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Drawing Up the Vaccine

Before drawing up vaccine:
 Verify correct vaccine type and name.
 Check expiration date.
 Check liquid for clarity, color.
 Practice proper hand hygiene.
 Draw up air into the syringe equal to the volume of
vaccine you will draw from the vial.
• Air will be injected into the vial when vaccine is drawn
up to equalize vial pressure.
 If using a prefilled syringe and needle tip, do NOT
expel air from the syringe (see
https://www.immunize.org/askexperts/administeri
ng‐vaccines.asp for more details).

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Drawing Up the Vaccine

Swab top of vial with alcohol Insert needle into vial Invert vial to draw up vaccine Tap to remove air bubbles

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Time to Practice
 Draw up 0.5 ml into syringe with a 5/8‐inch needle.

 Draw up 0.5 ml into syringe with a 1‐inch needle.

 Practice safe technique for recapping the needle.

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Immunization Administration

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Locating the Intramuscular Injection Site

 Intramuscular injections are
administered into the deltoid muscle.
 To locate the deltoid, use anatomical
landmarks.
 In adults, the midpoint of the deltoid
is in the middle of the upper arm and
approximately 2 inches (2‐3 fingers’
breadth) below the acromion process
and above the armpit.

https://www.cdc.gov/vaccines/hcp/infographics/ycts‐flu.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fhcp%2Finfographics%2Fyou‐call‐the‐shots‐intramuscular‐flu‐vaccination.html

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Administering an Intramuscular Injection

 Inject the vaccine into the
middle of the thickest part of
the deltoid muscle.
 Insert the needle at a 90‐
degree angle with a quick
thrust.
 If more than one vaccine in
the same arm, separate
injection sites by at least 1
inch.
How to Administer Intramuscular and Subcutaneous Vaccine Injections: https://www.immunize.org/catg.d/p2020.pdf

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Intramuscular Injection Steps

1. Wash hands, put on gloves.
2. The patient should be seated.
3. Identify injection site and uncover area.
4. Wipe with alcohol and let alcohol dry.
5. Tell patient to relax or ask a distracting question.
6. Insert needle at 90° to skin in a smooth controlled motion while bracing against the arm.
7. Depress the plunger.
8. Withdraw the needle swiftly.
9. Activate safety device immediately.
10. Dispose of syringe in sharps container (do not recap or set down!).
11. Press cotton or gauze if needed, apply adhesive bandage.
12. Wash hands. 33

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Shoulder Injury Related to Vaccine Administration

(SIRVA)
What is SIRVA?
 An injury caused by the injection of a vaccine too high
in the shoulder.
 Vaccine is inappropriately injected into the shoulder Acromion
capsule rather than the deltoid muscle.
 Resulting inflammation of the shoulder structures
causes patients to experience pain, a decreased range Deltoid
of motion, and a decreased quality of life. (injection site)

 Ensure you do not vaccinate too high and inject into

the shoulder joint!
 Sitting next to the patient rather than standing over
the patient can help avoid SIRVA.
• Bancsi A, Houle SKD, Grindrod KA. Shoulder injury related to vaccine administration and other injection site
events. Can Fam Physician. 2019;65(1):40–42.
• Barnes MG, Ledford C, Hogan KA. A “needling” problem: shoulder injury related to vaccine administration. J Am
Board Fam Med. 2012;25(6):919–22.

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Locating the Subcutaneous Injection Site

 Subcutaneous vaccines are administered into the fatty tissue overlying the triceps.

How to Administer Intramuscular and Subcutaneous Vaccine Injections: https://www.immunize.org/catg.d/p2020.pdf

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Administering a Subcutaneous Injection

 Pinch the tissue to prevent injection into
the muscle.
 Insert the needle at a 45‐degree angle.
 If more than one vaccine in the same
arm, separate injection sites by at least 1
inch.

How to Administer Intramuscular and Subcutaneous Vaccine Injections: https://www.immunize.org/catg.d/p2020.pdf

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Subcutaneous Injection Steps

1. Wash hands, put on gloves.
2. The patient should be seated.
3. Identify injection site and uncover area.
4. Wipe with alcohol and let alcohol dry.
5. Pinch fold of skin
6. Tell patient to relax or ask a distracting question.
7. Insert needle at 45° angle to skin while bracing against the arm
8. Depress the plunger.
9. Wait 2‐3 seconds to allow vaccine to absorb.
10. Withdraw the needle swiftly.
11. Activate safety device immediately.
12. Dispose of syringe in sharps container (do not recap or set down!).
13. Press cotton or gauze if needed, apply adhesive bandage.
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14. Wash hands.

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Additional Considerations
 Patient should be sitting.
• May want to use a chair with arms.
• Have adequate space to lay person down if necessary.
 Expect bleeding.
• Patient can hold cotton swab until bandage is placed.
 Hitting bone does not hurt patient.
 Avoid (when possible) scars, tattoos, and moles.
 Do not aspirate syringe while needle is in patient.

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Tips for a Nearly Pain‐free Injection

• Let the alcohol dry.
• Contact with your non‐injecting hand can be comforting.
• Insert needle with a smooth, darting motion.
• Don’t push too hard while you inject the vaccine.
• If you need to pinch or pull the skin, be gentle.
• For IM, try to inject in the center of the deltoid (too low is more painful,
too high risks SIRVA).
 Distract the patient by asking an open‐ended question if appropriate.

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Before You Administer an Immunization…

 Verify the patient has completed screening questionnaire.
 Verify the patient has received counseling from the pharmacist.
 Verify the patient has received the most current VIS.
 Verify the patient does not have any questions.
• If the patient does have questions, have the pharmacist talk to the patient.

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Before You Administer an Immunization…

 Ensure universal precautions are followed (hand hygiene, gloves, sharps
container).
 Make sure the patient is seated.
• This is critical the patient’s safety and your safety.
 Verify you have the correct patient (name and date of birth).
• “Just to confirm, could you please tell me your name and birthday?”
 Verify you have the correct vaccine (confirm with documentation and patient).
• “Just to confirm, are you here to get a shingles vaccine today?”
 Make sure the injection area is accessible and the patient’s shirt sleeve is not in
your way.
• If the patient’s shirt is tight avoid rolling up the sleeve, it can create a tourniquet and increase
bleeding.
 Swab the injection site with an alcohol swab.
• Allow the alcohol to dry before injecting.

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Your Turn!
 Practice with your partner
injecting into a practice pad or
orange

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Intranasal LAIV

How to Administer Intranasal and Oral Vaccinations: https://www.immunize.org/catg.d/p2021.pdf

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Documenting the Vaccination

Name of Lot # and Date VIS
Item to Injection
Vaccine Expiration Manufacturer Dose Route Date on VIS given to
document Site
Given Date patient

Write Location and

Volume of Subcutaneous,
brand name Information Information which arm Found on Today’s
Directions vaccine intramuscular,
(i.e. not just found on vial found on vial (i.e. right VIS date
administered intranasal
“influenza”) deltoid)

Cougar
Cougar
Influenza Lot: 123456
Example Manufacturing 0.5mL IM Right deltoid 01/01/2020 02/14/2020
Vaccine Exp: 03/30/20
Company
IIV4

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Emergencies

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Management of Localized Reactions

Signs and symptoms Management
Soreness, redness, itching, Apply a cold compress to the injection site. Consider
or swelling at the injection giving a pain reliever or anti‐itch medication
site
Slight bleeding Apply pressure and an adhesive compress over the
injection site.
Continuous bleeding Place thick layers of gauze pads over the site, maintain
direct and firm pressure; raise the injection site above
the level of the patient’s heart.

https://www.immunize.org/catg.d/p3082.pdf

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Patient Case: Juanita

 You immunize Juanita, a 42‐year‐old patient, during an immunization clinic. Juanita has
never had a flu shot before. The pharmacist reviews Juanita’s screening form questions
and determines an influenza vaccine is appropriate for her. After administering the
vaccine, you request that Juanita remain in the pharmacy for 15 minutes.
Approximately 5 minutes later, Juanita returns to the administration area stating that
she does not feel very well and would like a drink of water.

 What do you do?

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Management of Syncope (fainting)

Signs and symptoms Management
Fright before injection is given Have patient sit or lie down for the vaccination
Patient feels “faint” (e.g., light‐headed, Have patient lie flat. Loosen tight clothing and maintain an open airway.
dizzy, weak, nauseated, or has visual Apply a cool, damp cloth to the patient’s face and neck. Keep them
disturbances) under close observation until fully recovered.
Fall, without loss of consciousness Examine the patient to determine if injury is present before attempting
to move the patient. Place patient flat on back with feet elevated.

Fall, with loss of consciousness Check to determine if injury is present before attempting to move the
patient. Place patient flat on back with feet elevated. Call 911 if patient
does not recover immediately.

https://www.immunize.org/catg.d/p3082.pdf

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Management of Anaphylaxis (allergy)

1. If itching and swelling are confined to the injection site,
observe the patient closely for generalized symptoms.
2. If symptoms are generalized, call 911 and assess the airway,
breathing, circulation, and consciousness of the patient.
3. Administer epinephrine +/‐ diphenhydramine.
4. Monitor the patient closely until EMS arrives. Perform CPR
if necessary.
5. If EMS has not arrived and symptoms are still present,
repeat dose of epinephrine every 5‐15 minutes for up to 3
doses.
6. Document the reaction to the vaccine. Report the incident
to VAERS and notify the patient’s physician.

Medical Management of Vaccine Reactions in Adults in a Community Setting: https://www.immunize.org/catg.d/p3082.pdf

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Epinephrine
 If epinephrine is not available, DO NOT VACCINATE
 If epinephrine is administered, call 911
 Know how to use the epinephrine injector(s) available in your pharmacy
• Check the prescribing information online or the package insert for instructions
 Auvi‐Q prescribing information: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6180fb40‐7fca‐
4602‐b3da‐ce62b8cd2470&type=display

 EpiPen information and administration guide:

https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?type=display&setid=7560c201‐9246‐487c‐a13b‐6295db04274a

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Epinephrine

Auvi‐Q information and administration guide: https://www.auvi‐q.com/hcp/

EpiPen prescribing information : https://www.epipen.com/en/hcp

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Patient Case: Juanita (continued)

 Next, Juanita’s respirations become very labored and audible wheezes are
observed

 What do you do?

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Patient Case: Juanita (continued)

 Juanita’s breathing initially responds to the epinephrine; however, she
begins to wheeze and continues to have shortness of breath.

 What do you do?

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Emergency Preparedness Summary

 Locate emergency kit before immunizing.
 Have a plan and practice it.
 Observe for 15 minutes post‐vaccination.
 If reaction occurs:
• Evaluate severity and call 911 if necessary
• Administer epinephrine if necessary
• Monitor closely
• Be prepared for CPR
• Document events

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Summary of Procedure for Vaccine Administration

 Wash hands, put on gloves
 Prep supplies
 Check expiration dates
 Confirm right vaccine (be careful about look‐alike/sound‐alike names)
 Verify preparation instructions (many vaccines must be shaken)
 Maintain sterility while preparing the dose
 Draw up dose using appropriate technique
 Position sharps container within reach
 Activate safety device immediately
 Dispose of needle properly
 Remove gloves and wash hands
 Ensure proper documentation
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Questions?

Questions?

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Time for Practice and Skills Assessment

 You need to find a partner
 You will be giving and receiving 2 injections (1 IM and 1 SC) of normal saline
 Draw up 2 doses of saline in the appropriate syringes
 Complete documentation on front page

One of the faculty members must see both injections or they do not count
and you will have to repeat them

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