Immunizations need to be administered according to the 7 rights:
The right patient:
All patients should be screened for contraindications and precautions every time a vaccine is administered, even if the patient has previously received a dose of that vaccine. The patient's status can change from one visit to the next or a new contraindication or precaution may have been added.
Screening questions are available here.
The right vaccine or diluent:
Some vaccines need to be reconstituted; a specific diluent will be provided by the manufacturer. It is important to follow manufacturer guidelines in reconstituting the vaccine. See
Vaccines with Diluents: How to Use Them. Measles, mumps, rubella (MMR); varicella; zoster; meningococcal polysaccharide (MPSV); and rotavirus vaccines all require reconstitution.
The right time:
This includes administering at the correct age, the appropriate interval, and before vaccine or diluent expires. Check the
schedule to ensure the patient is getting the vaccine at the right time, and the appropriate
interval. Each vaccine vial should be checked for the expiration date. A vaccine should never be used if it is expired. Once reconstituted, the vaccine must be administered according to the guidelines or discarded. In most cases, if not used within 30 minutes, the vaccine will lose its potency and the patient will not be properly immunized.
The right dosage:
Vaccine administrators need to make sure they draw the correct amount of immunization when drawing from multidose vials. See
Administering Vaccines: Dose, Route, Site, and Needle Size.
The right route, needle length, and technique: (see Table 1 below)
Immunizations are administered through the following routes: intramuscular (IM), subcutaneous (SQ), oral, and nasal. The majority of immunizations are administered IM, but MMR, varicella, zoster, and MPSV are administered SQ. In administering IM injections, it is important to use a needle with the correct length to reach the muscle mass and not seep into SQ tissue.
When administering IM injections, the needle should be inserted at a 90° angle—and quickly. It is not necessary to aspirate after needle insertion. SQ injections are administered at a 45° angle, and the SQ tissue is pinched up to prevent injection into the muscle. It is not necessary to aspirate after needle insertion. Multiple immunizations should be a minimum of 1 inch apart. Another method of immunization is nasal spray, which has recently become available for live attenuated influenza vaccine. Oral polio vaccine has not been used in the United States since 2000 but is still used in other countries. In the United States, inactivated polio vaccine is given and can be administered SQ or IM./p>
The right site (see Table 2 below):
Children of different sizes and ages will need vaccines administered in different locations on the body.
The right documentation
Document the following:
- Vaccine manufacturer,a
- lot number,a
- date of administration,a
- Name and business address of the health care professional administering the vaccine,a
- Date that VIS is provided (and VIS publication dateb),
- Site (eg, deltoid area), c
- route (eg, intramuscular) of administration, c and
- and expiration date of the vaccinec
a Required under the National Childhood Vaccine Injury Act.
b Required by Centers for Disease Control and Prevention (CDC) regulations for vaccines purchased through CDC contract. See the VIS Web site for current versions.
c Recommended by the American Academy of Pediatrics.
Other important vaccine administration tips:
Do use a separate anatomic site for each injection.
Do label vaccines if more than one are drawn up together. This will help with documenting which vaccines were given in which site.
Do ensure that the person who drew up the vaccine administers it. This will reduce errors.
Do wash hands between patient encounters and before preparing vaccines
Do wear gloves to administer a vaccine if there is a risk coming into contact with body fluids or if the administrator has open sores or cuts on the hands.
Do consider immunizations for those with only a mild illness. Always screen for other contraindications.
Do use safety syringes to reduce the incidence of needle sticks and disease transmission.
Do check to see what size needle, route and location should be used.
Do give immunizations to patients with a mild illness. If a child has a moderate or severe illness – rescheduled their immunizations.
not mix separate vaccines in the same syringe. If more than one vaccine is being administered to the same limb, injection sites should be 1 to 2 inches apart so that any reactions can be determined.
not pre-draw your own syringes – these are vaccines that are drawn up in syringes and laid out at the beginning of the day or significantly before administration. It is ok to use prefilled syringes that come as single doses from the manufacturer.
Some immunizations come with a diluent and must be reconstituted, whereas others do not. Always follow the current recommended immunization schedule.
Adapted From AAP RedBook
Common Pediatric Vaccines Administered in the United States and Their Routes of Administration
| || || |
|Diphtheria-tetanus (DT, Td)||Toxoids||IM|
|DTaP||Toxoids and inactivated bacterial components||IM|
|DTaP, hepatitis B, and IPV||Toxoids and inactivated bacterial components, recombinant viral antigen, inactivated virus||IM|
|DTaP-IPV||Toxoids and inactivated bacterial components, inactivated virus||IM|
|DTaP-IPV/Hib (PRP-T reconstituted with DTaP-IPV)||Toxoids and inactivated bacterial components, polysaccharide-protein conjugate, inactivated virus||IM|
|Hepatitis A||Inactivated virus||IM|
|Hepatitis B||Recombinant viral antigen||IM|
|Hepatitis A-hepatitis B||Inactivated virus and recombinant viral antigens||IM|
|Hib conjugate (tetanus toxoid)
b ||Bacterial polysaccharide-protein conjugate||IM|
|Hib conjugate (PRP-OMP
b ) hepatitis B||Bacterial polysaccharide-protein conjugate with recombinant viral antigen||IM|
|Human papillomavirus (HPV2 and HPV4)||Recombinant viral antigens||IM|
|Influenza||Inactivated viral components||IM|
|Meningococcal polysaccharide (MPSV4)||Bacterial polysaccharide||SC|
|Meningococcal conjugate (MCV4)||Bacterial polysaccharide-protein conjugate||IM|
|Pneumococcal polysaccharide (PPSV)||Bacterial polysaccharide||IM or SC|
|Pneumococcal conjugate (PCV)||Bacterial polysaccharide-protein conjugate||IM|
|Poliovirus (IPV)||Inactivated viruses||SC or IM|
|Rotavirus (RV1 and RV5)||Live-attenuated virus||Oral|
|Tdap||Toxoids and inactivated bacterial components||IM|
From AAP Red Book: Site and Needle Length by Age for Intramuscular Immunization
Needle Length, inches (mm)
Suggested Injection Site|
|Newborns (preterm and term) and infants <1 mo of age||⅝ (16)
b ||Anterolateral thigh muscle|
|Term infants, 1–12 mo of age||1 (25)||Anterolateral thigh muscle|
|Toddlers and children||⅝ –1 (16–25)
b ||Deltoid muscle of the arm|
| ||1–1¼ (25–32)||Anterolateral thigh muscle|
|Adults|| || |
| Female and male, weight <60 kg||1 (25)
c ||Deltoid muscle of the arm|
| Female and male, weight 60–70 kg||1 (25)||Deltoid muscle of the arm|
| Female, weight 70–90 kg||1 (25)–1½ (38)||Deltoid muscle of the arm|
| Male, weight 70–118 kg||1 (25)–1½ (38)||Deltoid muscle of the arm|
|Female, weight >90 kg||1½ (38)||Deltoid muscle of the arm|
| Male, weight >118 kg||1½ (38)||Deltoid muscle of the arm|
a Assumes that needle is inserted fully.
b If the skin is stretched tightly and subcutaneous tissues are not bunched.
c Some experts recommend a ⅝-inch needle for men and women who weigh less than 60 kg.
Vaccine Administration Resources