Reducing Vaccine Administration Errors

1. Reducing Vaccine Administration Errors Susan Reeser, RN, BSN Nurse Consultant April 2013

2. “All medications are prescribed, prepared and administered with the best intentions to improve patient health and comfort.” Fundamentals of Nursingsecond edition

3. To Err is Human: Building a Safer Health System Institute of Medicine Report (1999) • Addressed medical errors

4. Objectives(Learning Outcomes) Describe one strategy to decrease vaccine administration errors Identify one resource for vaccine administration information

5. Overview Types of Vaccine AdministrationErrors Administering Vaccines Correctly “Rights” of Medication Administration PreventionStrategies Discussion Questions Resources

6. Types of Vaccination Errors • Storage and Handling • Administration • Scheduling • Documentation

7. Types of VaccineAdministration Errors • Wrong vaccine or diluent • Wrong dosage • Expired vaccine • Incorrect route/site/needle size • IAC

9. Adequate Training Current Immunization Education Administer Vaccines Correctly

10. Be Prepared to Administer Vaccines Correctly

11. Stay current with Immunization Updates • CDC Education and Training Website • Newsletters • Needle Tips • Vaccinate Adults • IAC Express • Conferences, Online Continuing Ed. • Others

12. Nursing and the “Rights” of Medication/Vaccine Administration

13. “Rights” of Medication Administration Right Patient Right Medication Right Time Right Dosage Right Manner/Route Right Documentation

14. 1. Right Patient • Right name? Has the patient received immunizations under another name? • Date of birth? (CS) • Do you have a copy of the patient’s IZ record? • Has the patient been screened for contraindications?

15. Screening Checklist

16. 2. Right Vaccine (Medication) • Check the label at least 3 times • before you draw up • after you prepare • again, before you administer • Right diluent

19. 3. Right Time SCHEDULE Right age Right interval 4-day grace period Before the expiration date

20. Pink Book Resource Tool

21. Important Rule Vaccine doses should not be administered at intervals less than the recommended minimal intervals or earlier than the minimum ages. But, there is no maximum interval (Except for oral typhoid vaccine in some circumstances)

23. 4. Right Dose Pediatric vs. adult Flu Other

25. 5. Right Route Oral Intranasal SC IM Needle length

26. 6. Right Documentation Critical to ensure the correct # of doses Not to waste vaccine Prevent reactions

28. Vaccine Documentation • Date VIS provided and the date printed on the VIS • Document: • Date vaccine administered • Vaccine manufacturer • Lot # • Clinic name and address and title of person who administered the vaccine • Only accept written, dated records • Use imMTrax if available

29. Strategies/Systems

30. How to Avoid Making Errors To ensure patient safety we need to learn from mistakes, our own and others.

31. Oh No, What Now?Discovering an Error • Use resources for what to do next • the dose may not need to be repeated • Contact the patient or parent to: • inform them of the error • check the patient status • explain the need for next steps

32. Discovering an Error Determine how and why the error occurred Develop a strategy for prevention Document per your facilities protocol VAERS reporting?

33. Discussion

34. Resources

35. CDC Resources The Pink Book: Course Textbook http://www.cdc.gov/vaccines/pubs/pinkbook/index.html Vaccines and Immunizations Education and Training http://www.cdc.gov/vaccines/ed/

36. Resources: Continuing Ed • CDC Immunization: You Call the Shots http://www.cdc.gov/vaccines/ed/youcalltheshots.htm • IAC EZIZ Training-California VFC http://eziz.org/eziz-training/ • Other

37. Immunization Action Coalition (IAC) Clinic Resources http://www.immunize.org/handouts/screening-vaccines.asp Handouts Screening Forms Ask the Experts Newsletters Etc.

38. Summary:How to Avoid Making Errors Adequate Skills Current Knowledge 3 Checks and “Rights” System Strategies Available Resources

39. Act as if what you do makes a difference. It does. William James It does. William James

40. Questions?

41. Credit to: Centers for Disease Control and Prevention (CDC) • Donna L. Weaver, RN,MN Immunization Action Coalition (IAC) • Deborah L Wexler, MD • Teresa A, Anderson, DDS, MPH

42. Thank You Susan Reeser RN, BSN Nurse Consultant sreeser@mt.gov (406) 444-1825