Tuesday, August 31, 2010

3rd Seminar. Medication errors with vaccines: improving with the professionals

Problem description:

The objective of the 2009 program-contract in our area on medication errors reporting was to report at least 109 errors, which means a 5% of the expected in an area like ours.

The total in 2009 was 192 errors reported. The 26% of these was related to vaccine administration.

Analysis of causes:

A working group is formed with 12 professionals involved in immunization and motivated on patient safety: a pediatrician, nurses and immunization managers. Members of the risk unit of the area coordinate the group.

The group performs an analysis of causes of vaccine-reported errors.

Professionals: lack of training, unclear labeling, bad registration on patient's medical records, bad anamnesis, more than one professional to vaccinate a patient.

Organizational: lack of information in the admission of new professionals and substitutes, neither clear labels nor clear information on vaccine refrigerators, no registration of the vial opening date, failure to follow protocols and institutional advices.

Agents and resources: Errors in OMI drug list, frequent changes in laboratory supplier, multi-dose vaccines, different vaccines with similar labeling, prescribing information in other language, small print on the packaging.

Improvement actions:

Elaboration of an informative brochure and poster on the most common mistakes with vaccines.

The brochure will be given to new professionals and substitutes who will work with vaccines at their welcome, and there will be named a manager for this task in each facility.

The poster will be located in all offices at the primary care facility.

Rearrangement of vaccines in the refrigerator by age of administration.

Development of visible reminders in the refrigerator on the identification and proper placement of vaccines.


We improve the involvement of professionals in the security ambit.

A professional group makes improvement proposals, which will facilitate its acceptance.

We will assess the impact of these measures with the report of the errors with vaccines throughout 2010.

Presentation by María Dolores Martínez Patiño, UFGRS of the 5th Area of Madrid.

+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20030.pdf

Posted by Fernando Palacio
English version by Erika Céspedes

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