Preventive Medicine: Be Sure Your Staff Is Not Making Any of These Frequently Reported Vaccine Administration Errors

December 2015

Technically Speaking
Monthly Column by Deborah Wexler, MD
Deborah Wexler MD
Technically Speaking is a monthly column written by IAC’s Executive Director Deborah Wexler, MD. The column is featured in The Children’s Hospital of Philadelphia Vaccine Education Center’s (VEC’s) monthly e-newsletter for healthcare professionals. Technically Speaking columns cover practical topics in immunization delivery such as needle length, vaccine administration, cold chain, and immunization schedules.
Check out a recent issue of Vaccine Update for Healthcare Providers. The VEC e-newsletter keeps providers up to date on vaccine-related issues and includes reviews of recently published journal articles, media recaps, announcements about new resources, and a regularly updated calendar of events.
TECHNICALLY SPEAKING
Preventive Medicine: Be Sure Your Staff Is Not Making Any of These Frequently Reported Vaccine Administration Errors
Published December 2015
Information presented in this article may have changed since the original publication date. For the most current immunization recommendations from the Advisory Committee on Immunization Practices, visit www.immunize.org/acip/acip_vax.asp.
Your patients count on you to administer vaccines safely, effectively and correctly. Unfortunately, vaccine administration errors occur too frequently in medical practices. Most of the time, these errors go unreported, or even worse, may not be recognized. Inadequate training in vaccine administration is a core problem for many medical practices.
To help elucidate the extent of the problem and to identify solutions, the Institute for Safe Medication Practices (ISMP), a nonprofit patient safety organization devoted to preventing medication errors and safe medication use, in collaboration with the California Department of Public Health, launched its Vaccine Errors Reporting Program (VERP) in September 2012. The VERP online error reporting system was created to allow healthcare professionals and patients to confidentially provide information about vaccine errors. By collecting and quantifying this information, ISMP determined it could better advocate at a national level for modifications (e.g., changes to similar vaccine names and labeling) that could reduce the likelihood of vaccine errors in the future. The information also could be used to teach about vaccine errors and how to avoid them.
VERP received 1,256 confidential reports of vaccine errors from September 2012 through June 2015. When these reports were broken down into categories, the two most commonly reported types of errors were (1) administering vaccine to the wrong-age patient and (2) administering the wrong vaccine to a patient. These two categories alone accounted for almost half of all reported errors.
What else can lead to vaccine administration errors? The frequency of errors reported to VERP is reflected in the percentages below:
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Wrong age: 24 percent
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Wrong vaccine: 24 percent
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Extra dose: 10 percent
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Too large a dose: 10 percent
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Expired vaccine: 8 percent
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Wrong interval: 7 percent
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Component omission: 5 percent
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Underdose: 5 percent
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Wrong patient: 4 percent
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Wrong route: 3 percent
To avoid vaccine errors in your practice setting, please make use of the resources below to train staff in how to avoid them. Remember, your efforts to apply preventive health measures for your patients include prevention of vaccine administration errors!
From ISMP
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Confusion Abounds! 2-year Summary of the ISMP National Vaccine Errors Reporting Program VERP summary report (Part 1)
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Recommendations for Practitioners to Prevent Vaccine Errors Part 2: Analysis Of ISMP Vaccine Errors Reporting Program (VERP)
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Vaccine Error Reporting Program (VERP) website
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About the Institute for Safe Medication Practices
From IAC
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Administering Vaccines: Dose, Route, Site, and Needle Size
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How to Administer Intramuscular and Subcutaneous Injections
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How to Administer Intradermal, Intranasal, and Oral Vaccinations
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Training DVD: Immunization Techniques: Best Practices with Infants, Children, and Adults for a nominal charge with bulk purchase discounts
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Guide to Contraindications and Precautions to Commonly Used Vaccines
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Vaccines with Diluents: How to Use Them
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More Clinic Resources: Administering Vaccines
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More Clinic Resources: Storage and Handling of Vaccines
From CDC
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Injection safety Web page
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ACIP General Recommendations on Immunizations
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Vaccine Administration chapter, Epidemiology and Prevention of Vaccine Preventable Diseases, 13th edition, 2015
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Provider’s Role: Importance of Vaccine Administration and Vaccine Storage & Handling
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Vaccine Administration Web page
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Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines
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Slide set: Vaccine Administration: Frequent Errors and Prevention Strategies
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Hibbs, BF, et al. Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000-2013. Vaccine. 2015 Jun 22;33(28):3171-8.
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Notes from the Field: Rotavirus Vaccine Administration Errors — United States, 2006–2013 (MMWR, 2014, 63(4):81)
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Notes from the Field: Reports of Expired Live Attenuated Influenza Vaccine Being Administered — United States, 2007-2014 (MMWR, 2014, 63 (35):773)
Where to Report Vaccine Errors
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ISMP Vaccine Error Reporting Program (VERP) website
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CDC’s Vaccine Adverse Events Reporting System

 

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