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
A New Program for Reporting Vaccine Errors
Published December 2012
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.
Over the years, the Immunization Action Coalition has received hundreds of questions about vaccination procedural errors and what to do about them or where to report them. Some common errors include administering the wrong vaccine or the wrong dose; giving a vaccine before the minimum age or interval; administering the vaccine by the wrong route or at the wrong anatomic site; reconstituting a vaccine improperly; using expired or improperly handled vaccine; or even vaccinating the wrong patient. The Institute for Safe Medication Practices recently launched an online website to report vaccine errors.
ISMP is a nonprofit, federally-certified patient safety organization, respected worldwide as the premier resource for medication safety information. Founded in 1994, ISMP works closely with healthcare practitioners and institutions, regulatory agencies, consumers and professional organizations to provide education about medication errors and prevention.
With the assistance of the California Department of Public Health, ISMP developed the ISMP Vaccine Error Reporting Program (VERP). VERP was created to allow healthcare professionals to report vaccine errors anonymously; ISMP guarantees confidentiality concerning the information it receives. The purpose of VERP is to capture the unique causes and consequences of vaccine-related errors. By collecting and quantifying information about these errors, ISMP will be better able to advocate for changes in vaccine names, labeling or other appropriate modifications that could reduce the likelihood of vaccine errors in the future.
The reporting system asks for detailed information about the occurrence, including:
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A description of what went wrong
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Identification of any known causes or contributing factors
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How the event was discovered or intercepted
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Outcome for the patient(s) involved
The system also requests that users share their recommendations for prevention of similar errors.
VERP is not to be confused with VAERS, the Vaccine Adverse Events Reporting System. VAERS, a national vaccine safety surveillance program co-sponsored by the Centers for Disease Control and Prevention and the Food and Drug Administration, is intended to be the location for reporting adverse events that occur following the administration of a vaccine to a patient. VAERS reports should be submitted regardless of whether or not the reporter believes the adverse event was vaccine-related. Although healthcare professionals have sometimes reported vaccine administration errors to VAERS in the past, the new VERP system provides a more logical location for these reports, allowing for a clear separation between reporting of adverse events in a patient (VAERS) from procedural errors that may or may not result in adverse events (VERP). Of course, both VAERS and VERP may be used for the same event when the situation warrants it.
