Earlier this year a Kiwi nurse was censured by the Health & Disability Commission for giving a 12-year-old girl the wrong vaccine after assuming she had come for her 11-year-old ‘booster’ vaccination.
This followed the censuring last year of another nurse who, in a rush, mixed up one of the vaccines for a 15-month-old after she couldn’t find the yellow card (the Ministry of Health’s National Immunisation Schedule reference card) that spells out which vaccines to deliver at each age milestone.
Neither child was harmed, but sadly, in Samoa, two nurses are awaiting trial after the tragic deaths of two infants following MMR vaccinations. The cause of the deaths is still unknown, but Samoa’s use of multi-dose vials of the MMR vaccine raises questions over dilution errors.1
New Zealand uses the single-dose MMR vaccine with the diluent provided in a prefilled syringe in the same package. This minimises the risk of dilution errors, but other minor errors remain a risk – the same as in any medication administration environment. This is particularly the case for busy practice nurses juggling elderly patient phone calls, GP requests to squeeze in patients’ blood tests or wound dressings, plus waiting rooms of stressed mums with restless toddlers and crying babies.
New Zealand’s immunisation standards for vaccinators are provided in the appendix of the Immunisation Handbook 2017 to guide nurses and other vaccinators on competent deliveries of safe and effective immunisation services so a patient doesn’t receive the wrong vaccine at the wrong age or by the wrong route or at the wrong interval. The handbook also provides, in another appendix, specific instructions for the preparation (including the reconstitution) and the administration of vaccines.
Nursing Review talked to Immunisation Advisory Centre (IMAC) education coordinator Trish Wells-Morris and checked out Health Quality & Safety Commission advice for tips on safe vaccination and infection control for busy nurses.
Wells-Morris says New Zealand has access to very good quality vaccines that are supplied ready for use and delivered via pre-filled syringes. “So the opportunity for contamination or to make a mistake is minimised.”
When a very occasional vaccination error occurs, she says New Zealand’s open and voluntary approach to incident reporting means nurses will often ring IMAC’s 0800 IMMUNE number to discuss concerns and whether any further action is needed.
“Organisations have quality systems to follow up and investigate any incidents and it’s a non-punitive system that works best.”
These errors usually don’t cause harm; for example, a lack of documentation resulting in a child inadvertently receiving the same vaccine twice. “So the nurse is concerned about any harm to the baby… that the baby has had an extra vaccine and will they suffer… fortunately, babies are very resilient.”
But it’s a given that no nurse wants to cause anxiety or the risk of harm to a patient through avoidable human error.
Don’t shortcut pre-vaccination checks
Following a clear pre-vaccination check list, including gaining informed consent, helps to ensure the right vaccines are given to the right child or adult.
But a rushed nurse – working with a mother distracted by tired and fractious children – can miss a check and risk an error happening.
“Take a few breaths, slow down, and follow the process,” recommends Wells-Morris. “The potential for error increases if corners are cut.” This is particularly the case when everybody is busy, children are crying and a hard-working practice nurse is under pressure.
The pre-vaccination check includes not only screening to check there is no reason why the vaccine/s shouldn’t be given that day but also which vaccine the child or adult is due to have and what their current vaccination status is.
In the case of a child, Wells-Morris says that may involve checking firstly their Well Child record; secondly the practice’s electronic patient management system record; and thirdly, the National Immunisation Register.
Checking is particularly important if the family are new or infrequent visitors to the practice and they may have had an opportunistic vaccination at another practice by an outreach nurse or during a hospital visit. With no national register for adults, nurses must rely on patient recall.
When the vaccines are taken out of the vaccine fridge, the vaccine expiry date is checked and the nurse visually checks the vials for any contaminants; for example, if anything has broken off the rubber seal that could be drawn up into the syringe.
Wells-Morris says ideally at this point the vaccinator would check the selected vaccines with another vaccinator using the yellow card to ensure that they are the correct vaccines for the child in question.
In the two recent Health & Disability Commission complaints mentioned in the opening paragraphs, the vaccinating nurses’ errors were not picked up. In one case, they had mislaid the card and failed to correctly inform the checking nurse of the child’s age. In the other case, the checking nurse was told the 12-year-old girl was having her 11-year-old Boostrix vaccine rather than the requested Gardasil.
The HDC’s expert nurse advisor in the Gardasil case suggested that the vaccine check should have been done in the same room as the patient and, if working alone, a nurse could use the caregiver or patient to confirm the vaccine. Wells-Morris agrees that, in the right circumstances, nurses may wish to ask a parent or caregiver to check the vaccines against the Ministry’s yellow card.
Gaining informed consent from the caregiver or adult to each vaccine administered is also another safeguard.
Once the right vaccine is consented and confirmed, the nurse draws up and mixes the vaccine and administers it as directed on the vaccine’s data sheet. They then document the vaccine details, including on the National Immunisation Register and Well Child book if vaccinating a child, to complete the records.
Common vaccine errors and causes
- Wrong vaccine: often because they have similar names or cover the same diseases i.e. Infanrix.
- Wrong interval between doses: the immunisation history is not up to date.
- Wrong age: usually involves vaccines with age restrictions or different vaccines targeted at different age groups.
- Wrong injection site or route: an intramuscular vaccine given in site without enough muscle, or MMR given intramuscularly rather than subcutaneously.
- Wrong patient: multiple siblings turning up at the same time to a busy clinic for vaccinations.
- Incorrectly prepared vaccines: multiple component vaccines where an extra component, e.g. Hib, is not added or only the diluent is administered.
- Expired vaccine used: nurse forgot to check or the expiry date is unreadable.
- Cold chain failures: failure to keep vaccines at 2–8 degrees C at all times.
Tips for avoiding vaccine errors
- Store vaccines appropriately in a pharmaceutical refrigerator to reduce risk of child/adult vaccine formulations or vaccines with similar names being confused.
- Always confirm which vaccine the adult or child has presented for.
- Check their vaccination status via health records and, if a child, via the National
- Immunisation Register to avoid double-up errors and ensure correct interval between vaccine doses.
- When administering two component vaccines like DTaP-IPV-HepB/HiB (Infanrix hexa), document both vials’ details before vaccinating to reduce risk of missing HiB.
- Get a colleague to check you have the correct vaccines for the correct child using the Ministry of Health’s immunisation schedule yellow card guide.
- Involve the parent or patient in verifying you are administering the right vaccine, as well as getting informed consent.
- If more than one child from the same family is being seen, only bring one child’s vaccines into the room at a time.
- Check the child’s identity by using both name and birth date prior to administering each vaccine.
- Promptly document the details of vaccines given in the health record and, if a child, in the National Immunisation Register so the vaccination status is updated for future vaccinators.
Sources: Health Quality & Safety Commission, Medication Safety Watch, October 2015
- Immunisation Advisory Centre’s vaccine administration overview: www.immune.org.nz/health-professionals/vaccine-administration-overview
- Ministry of Health Immunisation Handbook 2017: includes the Immunisation Standards for Vaccinators: www.health.govt.nz/publication/immunisation-handbook-2017
- Vaccination video guides: IMAC has vaccination guide videos available on its community pharmacist advice page: www.immune.org.nz/pharmacists
- Cold chain guidelines: www.health.govt.nz/publication/national-standards-vaccine-storage-and-transportation-immunisation-providers-2017
The WHO-approved MMR vaccine used in Samoa is delivered in multidose vials containing five doses, and vaccines from the same batch have been used safely around the world. (The only multidose vial vaccine used in New Zealand is the BCG vaccine, which is only administered by specially trained vaccinators.) Samoa’s Commission of Inquiry into the deaths of two infants who died after being administered the MMR vaccine in July was adjourned in September until after the court case of the two nurses charged with manslaughter is heard early next year. The cause of the deaths is still unknown, but there have been calls in Samoa for ongoing nurse training, with indications that human error may have been involved in the dilution of the multidose vaccine.