To Err Is Human; To Not Err Is Better! Vaccination Errors and How to Prevent Them

Background:
The Immunization Action Coalition (IAC) is a nonprofit organization that works to increase immunization rates and prevent disease. Thousands of healthcare professionals call or write us every year with questions about vaccines and immunization, too many of which are cries for help regarding medical errors.

Setting:
Visitors to IAC's websites can contact IAC via an “admin” email address which directs mail to an IAC consultant for response. For more than a year, IAC has kept a record of the vaccination errors described by the writers.

Population:
Healthcare professionals around the nation who provide immunizations, including physicians, nurses, medical assistants, physician assistants, pharmacists, etc.

Project Description:
Common vaccination errors fall into the following categories: storage and handling, administration, scheduling, and documentation. This presentation will provide detailed information about the possible types of errors (using real examples), what to do if such an error occurs, and most importantly, how to prevent mistakes in the first place. For example, administration errors include using the wrong vaccine or diluent; the wrong dosage; expired vaccine; or providing the vaccine by the wrong route, site, or needle size. Common scheduling errors include giving a vaccine before the minimum age, not allowing for the minimum interval, and re-starting a series because of a long interval. Related resources from CDC and other organizations will be highlighted.

Results/Lessons Learned:
Unfortunately, vaccine errors occur all too frequently. The result of making such errors can be serious, including harm to the vaccinee from a side effect or vulnerability to disease, inconvenience to the parent/patient and likely related ill will, unreimbursed cost to the provider, and loss of trust in the provider with possible negative publicity or even legal action. Avoiding such errors benefits everyone.