| Technically Speaking |
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| Monthly Column by Deborah Wexler, MD |
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| 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. |
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| 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. |
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| TECHNICALLY SPEAKING |
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| Preventive Medicine: Be Sure Your Staff Is Not Making Any of These Frequently Reported Vaccine Administration Errors |
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| Published December 2015 |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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 |
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| 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! |
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From ISMP |
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From IAC |
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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) |
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Where to Report Vaccine Errors |
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ACIP Recommendations
Vaccine Information Statements 
