From the August 2008 issue

Earlier this month, we received three separate reports that described vaccine errors in which children received incorrect vaccine products in their pediatrician’s office. In two of the cases, an adult booster form of diphtheria, tetanus, and pertussis toxoids was given to a child less than 7, while in a third case, a 13-year-old girl received a similar product meant for children less than 7 years old. Similarities between the non-proprietary names and vaccine abbreviations (DTaP and Tdap) are believed to have contributed to the confusion. Separate stock of the pediatric and adult formulations, use shelf-talkers to direct staff to the location of each formulation, and place alerts on the products (e.g., “Adult” or “Pediatric”) and on automated dispensing cabinet screens, if applicable. The Joint Commission’s National Patient Safety Goal #13 requires accredited facilities to “encourage the patient’s active involvement in their own care as a safety strategy.” To accomplish this, consider including parents or caregivers in safety processes. For example, make them aware of the names of vaccines that are needed by writing them down beforehand or handing the patient a printed sheet that also details the purpose of each vaccine. (CDC requires that vaccine information statements [VIS], which include age requirements, be given out before each vaccination [www.cdc.gov/vaccines/Pubs/vis/default.htm].) Dispense unit-dose syringes wherever possible, and have nurses read the names of the vaccines aloud, with simultaneous confirmation by the parent. It might even be possible to use the vaccine log on the patient’s chart so that confirming the lot number and expiration date is included in the verification process. Have both the nurse and the parent sign and date the log.