Improving the safety of vaccine delivery

Evans, H. P.; Cooper, Alison; Williams, Huw; Carson‐Stevens, Andrew

doi:10.1080/21645515.2015.1137404

Cited by 8 publications

(8 citation statements)

References 13 publications

(20 reference statements)

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“…The IE occur at an alarming frequency (7) . Studies conducted in developed countries have found a high rate of IE involved in vaccine administration (3,(8)(9) .…”

Section: Introductionmentioning

confidence: 99%

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Retrospective study of immunization errors reported in an online Information System

Barboza

Guimarães

Gimenes

et al. 2020

Rev. Latino-Am. Enfermagem

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Objective: to analyze the immunization errors reported in an online Information System. Method: retrospective study conducted with data from the Adverse Event Following Immunization Surveillance Information System. Immunization errors were analyzed with respect to demographic characteristics and the vaccination process. Frequencies and error incidence rates have been calculated. Binomial and chi-square tests were used to verify differences in the proportions of the variables. Results: 501 errors were analyzed, the majority involving routine doses (92.6%), without Adverse Event Following Immunization (90.6%) and in children under five years old (55.7%). The most frequent types of errors were inadequacy in the indication of the immunobiological (26.9%), inadequate interval between doses (18.2%) and error in the administration technique (14.2%). The overall error incidence rate was 4.05/100,000 doses applied; the highest incidences of routine vaccines were for human rabies vaccine, human papillomavirus and triple viral; the incidence rate of errors with Adverse Events Following Immunization was 0.45/100,000 doses applied. Conclusion: it was found that immunization errors are a reality to be faced by the health systems, but they are amenable to prevention through interventions such as the adoption of protocols, checklists and permanent education in health.

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“…The IE occur at an alarming frequency (7) . Studies conducted in developed countries have found a high rate of IE involved in vaccine administration (3,(8)(9) .…”

Section: Introductionmentioning

confidence: 99%

“…Approximately one third of users experience at least one IE (7) . In a systematic review carried out in five Englishspeaking countries, a prevalence of vaccination error of 1.15 per 10,000 doses of vaccines was identified (10) .…”

Section: Introductionmentioning

confidence: 99%

Retrospective study of immunization errors reported in an online Information System

Barboza

Guimarães

Gimenes

et al. 2020

Rev. Latino-Am. Enfermagem

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“…In order to ensure patient safety and quality care, weaknesses must be identified and changes must be implemented to improve the safety of vaccines at different levels: from patient interventions to organizational actions at local, national, and international levels 29 . Teaching-service-community integration can be a strategy for changes in professional practice, the health care model, consequently, improving health services and patient safety 30 .…”

Section: /14mentioning

confidence: 99%

Assessment of Patient Safety in Vaccination Rooms

Teixeira

Ferreira

Felix

et al. 2021

Texto contexto - enferm.

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Objective: identify adherence to patient safety recommendations in the vaccination room. Method: this is a cross-sectional study that analyzed 463 vaccination procedures in six vaccination rooms in Minas Gerais from June to July 2018. Data were obtained with the application of the Patient Safety Checklist for Vaccination Rooms through systematic observation of the vaccination procedure. Descriptive statistics were used for data analysis. Results: 463 vaccination procedures were observed, and the mean overall adherence score was 58.5%, min. 43.3% and max. 74.1%. The items of higher adherence were related to the records of vaccine data (name, date, and batch) on the vaccination card; vaccine application with dose, route of administration, location and correct materials; and records in an information system. The items of lower adherence were related to health guidance; investigation of adverse events following immunization and the health status of the vaccinated person; records of vaccine laboratory and vaccination center on the vaccination card; vaccine workforce handwashing; and proper vaccine preparation. Conclusion: the mean overall score found in this study was 58.5% for the adherence to recommendations for vaccination procedures. This result highlights the need for educational interventions that promote patient safety in the vaccination room and studies analyzing the factors that prevent such adherence.

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“…Root cause analyses described in other studies identified clinic-specific approaches to prevent error, including decreasing distractions for registered nurses administering vaccines and redesigning vaccine storage rooms [ 31 ]. On a larger scale, recommendations include investing in health information technology that allows for unified immunization records and decision support tools to prevent mistiming or wrong number of vaccine doses [ 29 , 33 , 35 ]. A randomized controlled trial of an immunization prompting system with pediatric residents in a hospital-based clinic resulted in reduced vaccine administration errors and less missed opportunities to vaccinate [ 36 ].…”

Section: Ambulatory Pediatric Errors and Interventions To Prevent Errmentioning

confidence: 99%

Patient Safety in Ambulatory Pediatrics

Huth

Hotz

Starmer

2020

Curr Treat Options Peds

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Purpose of Review The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics. Recent Findings The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety. Summary There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized. Patient Safety (Ma Coffey, Section Editor) Medication errors Wrong drug prescribed or administered Wrong dose prescribed or administered Wrong route prescribed or administered Wrong frequency or duration prescribed or administered Omitted or duplicated dose Drug-drug interaction Known allergy Vaccine errors Wrong timing of vaccine Wrong route of administration Storage and dispensing errors Wrong vaccine administered Diagnostic errors Errors in the evaluation of signs and symptoms Errors in follow-up of diagnostic tests Errors related to missed, incorrect or delayed diagnoses Misfiled or erroneously entered patient information Lack of consent for an adult accompanying a child Delay in office care Wrong patient registered or treated Care coordination and care transition errors Verbal or written handoff communication failure Coordination errors including delayed access to medications, medical equipment and supplies Patient Safety in Ambulatory Pediatrics Huth et al.

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Improving the safety of vaccine delivery

Cited by 8 publications

References 13 publications

Retrospective study of immunization errors reported in an online Information System

Retrospective study of immunization errors reported in an online Information System

Assessment of Patient Safety in Vaccination Rooms

Patient Safety in Ambulatory Pediatrics

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