Vaccine Errors in North Carolina

1. Vaccine Errors in North Carolina Lisa Johns, RN, BSN Clinical Consultant North Carolina Immunization Branch

2. Most Common Errors by UCVDP Providers in NC • Giving Pentacel without the Hib component • Giving Td/Tdap/DTaP to the wrong age group • Giving adult formulation vaccines to children (or childhood formulations to adults) • Not observing minimum intervals and recommended schedules

3. Why are so many vaccine errors being made? • Inadequate staff training • Lack of familiarity with newer vaccines • Unclear medication administration policies • Disorganized storage and handling of vaccines

4. How Can Errors be Prevented? • Follow the “5 Rights” of safe medication administration • Improve training for new staff • Provide on-going training for current staff • Ensure on-site immunization resources are available for staff • Store vaccines in an organized manner • Develop written medication administration policies

5. Medication Error Reporting • Report medication errors anonymously to Institute of Safe Medication Practices (www.ismp.org) • If an adverse event occurs because of the error, file a VAERS report (http://vaers.hhs.gov) • Notify the patient/parent of the error • Establish corrective action plan • You are not required to report vaccine errors to the Immunization Branch

6. VAERS Reporting in NC Preferred method for reporting is via http://vaers.hhs.gov. Print a copy of the completed report and send it to the Immunization Branch OR You can fax or mail a completed VAERS report to VAERS or the Immunization Branch

7. Advantages of Electronic VAERS Reporting • Legibility of report • Completeness of report • Received quickly at VAERS • Makes it easier for VAERS to follow up directly with provider

8. Important Resources for Immunization Providers • The Pink Book, (11th ed.) published by CDC (On-line and in print) • ACIP General Recommendations, 2006 (On-line) • State laws (www.immunizenc.com) • www.cdc.gov/vaccines • Immunization Action Coalition (www.immunize.org) • National Network for Immunization Information ( www.nnii.org)

9. Thank you for all you do!