Pediatric vaccination errors: Application of the "5 Rights" framework to a national error reporting database

Vaccine

Volumn 27, Issue 29, 2009, Pages 3890-3896

  Bundy, David G ^a   Shore, Andrew D ^b   Morlock, Laura L ^b   Miller, Marlene R ^a,b  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH   (United States)

Author keywords

Ambulatory care; Medication errors; Vaccines

Indexed keywords

CHICKENPOX VACCINE; CYTOMEGALOVIRUS ANTIBODY; DIPHTHERIA PERTUSSIS POLIOMYELITIS TETANUS HEPATITIS B VACCINE; DIPHTHERIA PERTUSSIS TETANUS HAEMOPHILUS INFLUENZAE TYPE B VACCINE; DIPHTHERIA PERTUSSIS TETANUS VACCINE; DIPHTHERIA TETANUS TOXOID; HAEMOPHILUS INFLUENZAE TYPE B HEPATITIS B VACCINE; HAEMOPHILUS INFLUENZAE TYPE B VACCINE; HEPATITIS A HEPATITIS B VACCINE; HEPATITIS A VACCINE; HEPATITIS B ANTIBODY; HEPATITIS B VACCINE; HERPES ZOSTER IMMUNOGLOBULIN; INFLUENZA VACCINE; MEASLES MUMPS RUBELLA VACCINE; MEASLES VACCINE; MENINGOCOCCUS VACCINE; MUMPS VACCINE; PALIVIZUMAB; PNEUMOCOCCUS VACCINE; POLIOMYELITIS VACCINE; RABIES IMMUNOGLOBULIN; RABIES VACCINE; RECOMBINANT HEPATITIS B VACCINE; RUBELLA VACCINE; TETANUS ANTIBODY; TYPHOID VACCINE;

ADOLESCENT; ARTICLE; CHILD; CHILD HEALTH CARE; DATA BASE; DOSE CALCULATION; DRUG ADMINISTRATION ROUTE; DRUG DOSE REGIMEN; DRUG LABELING; DRUG QUALITY; FEMALE; HUMAN; INFANT; MAJOR CLINICAL STUDY; MALE; MEDICATION ERROR; PATIENT IDENTIFICATION; PREDICTION; PRESCHOOL CHILD; PRESCRIPTION; PRIORITY JOURNAL; SCHOOL CHILD; VACCINATION;

ADOLESCENT; CHILD; CHILD, PRESCHOOL; FEMALE; HUMANS; INFANT; INFANT, NEWBORN; MALE; MEDICATION ERRORS; RISK ASSESSMENT; VACCINATION;

EID: 67349220402     PISSN: 0264410X     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.vaccine.2009.04.005     Document Type: Article

References (46)

1. Ten great public health achievements-United States, 1900-1999. MMWR Morb Mortal Wkly Rep 1999;48(April (12)):241-3.
2. Maciosek M.V., Coffield A.B., Edwards N.M., Flottemesch T.J., Goodman M.J., and Solberg L.I. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 31 July (1) (2006) 52-61
3. Impact of vaccines universally recommended for children-United States, 1990-1998. MMWR Morb Mortal Wkly Rep 1999;48(April (12)):243-8.
4. National, state, and local area vaccination coverage among children aged 19-35 months-United States, 2006. MMWR Morb Mortal Wkly Rep 2007;56(August (34)):880-5.
5. Chen R.T., and Hibbs B. Vaccine safety: current and future challenges. Pediatr Ann 27 July (7) (1998) 445-455
6. Information for health-care workers: managing adverse events. World Health Organization. Available at: http://www.who.int/immunization_safety/aefi/managing_AEFIs/en/print.html [last accessed 29.04.09].
7. Jodar L., Duclos P., Milstien J.B., Griffiths E., Aguado M.T., and Clements C.J. Ensuring vaccine safety in immunization programmes-a WHO perspective. Vaccine 19 February (13-14) (2001) 1594-1605
8. Kron T. Stepping beyond the 5 rights of administering drugs. Am J Nurs July (62) (1962) 62-63
9. The Five Rights: a destination without a map. Institute for Safe Medication Practices. Available at: http://www.ismp.org/newsletters/acutecare/articles/20070125.asp [last accessed 29.04.09].
10. Santell J.P., Hicks R.W., McMeekin J., and Cousins D.D. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol 43 July (7) (2003) 760-767
11. Santell JP. Medication errors: experience of the United States Pharmacopeia (USP). Jt Comm J Qual Patient Saf 2005;31(February (2)):114-9.
12. National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Available online at: http://www.nccmerp.org [last accessed 29.04.09].
13. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993;50(February (2)):305-14.
14. Rao J.N.K., and Scott A.J. On chi-squared tests for multiway contingency tables with cell proportions estimated from survey data. Ann Stat 12 1 (1984) 46-60
15. Thomas D.R., Singh A.C., and Roberts G.R. Tests of independence on two-way tables under cluster sampling: an evaluation. Int Stat Rev 64 3 (1996) 295-311
16. U.S. Census Bureau, Population Division. Population estimates. Complete state dataset available at: http://www.census.gov/popest/datasets.html [last accessed 29.04.09].
17. Miller M.R., Robinson K.A., Lubomski L.H., Rinke M.L., and Pronovost P.J. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care 16 April (2) (2007) 116-126
18. Varricchio F. Medication errors reported to the vaccine adverse event reporting system (VAERS). Vaccine 20 August (25-26) (2002) 3049-3051
19. Varricchio F., and Reed J. Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS). South Med J 99 May (5) (2006) 486-489
20. Adacel (Tdap) and Daptacel (DTaP) confusion. Institute for Safe Medication Practices. Available at: http://www.ismp.org/Newsletters/acutecare/articles/20060824_2.asp?ptr=y [last accessed 29.04.09].
21. Sidebotham P.D., and Lenton S.W. Incidence of adverse reactions after administration of high dose diphtheria with tetanus vaccine to school leavers: retrospective questionnaire study. BMJ 313 August (7056) (1996) 533-534
22. ISMP Medication Safety Alert! Acute care edition. May 15, 2002 safety briefs. Institute for Safe Medication Practices. Available at: http://www.ismp.org/newsletters/acutecare/archives/May02.asp#may15 [last accessed 29.04.09].
23. ISMP Medication Safety Alert! Acute care edition. March 20, 2003 safety briefs. Institute for Safe Medication Practices. Available at: http://www.ismp.org/newsletters/acutecare/archives/Mar03.asp#Mar20 [last accessed 29.04.09].
24. Grabenstein JD. Advantages of standardizing vaccine and antibody nomenclature. J Am Pharm Assoc (2003) 2008 Jan-Feb;48(1):105-7.
25. Vaccine Identification Standards Initiative (VISI). Centers for Disease Control and Prevention. Available online at http://www.cdc.gov/vaccinesafety/vaxtech/visi/ [last accessed 29.04.09].
26. Filik R., Purdy K., Gale A., and Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors 48 Spring (1) (2006) 39-47
27. Levine S.R., Cohen M.R., Blanchard N.R., Frederico F., Magelli M., Lomax C., et al. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther 6 (2001) 427-443
28. Notice to readers: inadvertent intradermal administration of tetanus toxoid-containing vaccines instead of tuberculosis skin tests. MMWR Morb Mortal Wkly Rep 2004;2004;53(July (29)):662-4.
29. Aspden P., and Institute of Medicine (U.S.). Committee on Identifying and Preventing Medication Errors. Preventing medication errors (2007), National Academies Press, Washington, DC
30. Hazard alert! Confusion between tetanus-diphtheria toxoid (Td) and tuberculin purified protein derivative lead to unnecessary treatment. Institute for Safe Medication Practices. Available at: http://www.ismp.org/hazardalerts/confusion.asp [last accessed 29.04.09].
31. Zissman EN, Cain KK. AAP jump-starts discussions on vaccine barcodes. AAP news; March 2009. Available online at http://www.aapnews.org [last accessed 29.04.09].
32. Derrough T.F., and Kitchin N.R. Occurrence of adverse events following inadvertent administration of childhood vaccines. Vaccine 21 November (1-2) (2002) 53-59
33. Recommended immunization schedules for children and adolescents-United States, 2008. Pediatrics 2008;121(January (1)):219-20.
34. Butte A.J., Shaw J.S., and Bernstein H. Strict interpretation of vaccination guidelines with computerized algorithms and improper timing of administered doses. Pediatr Infect Dis J 20 Jun (6) (2001) 561-565
35. Vivier P.M., Alario A.J., Simon P., Flanagan P., O'Haire C., and Peter G. Immunization status of children enrolled in a hospital-based medicaid managed care practice: the importance of the timing of vaccine administration. Pediatr Infect Dis J 18 September (9) (1999) 783-788
36. Feikema S.M., Klevens R.M., Washington M.L., and Barker L. Extraimmunization among US children. JAMA 283 10 (2000 Mar 8) 1311-1317
37. Hamlin J.S., Wood D., Pereyra M., and Grabowsky M. Inappropriately timed immunizations: types, causes, and their relationship to record keeping. Am J Public Health 86 December (12) (1996) 1812-1814
38. Immunization information systems progress-United States, 2006. MMWR Morb Mortal Wkly Rep 2008;57(March (11)):289-91.
39. Rabello A., Orsini M., Disch J., Marcial T., Leal Md Mda L., Freire Md Mda S., et al. Low frequency of side effects following an incidental 25 times concentrated dose of yellow fever vaccine. Rev Soc Bras Med Trop 35 March-April (2) (2002) 177-180
40. Nishioka Sde A., and Lomonaco Ade F. Overdose of yellow fever vaccine: a preventable error?. Rev Soc Bras Med Trop 35 September-October (5) (2002) 541-542
41. Petridou E., Kouri N., Vadala H., Dalamaga M., and Sege R. Frequency and nature of recorded childhood immunization-related errors in Greece. J Toxicol Clin Toxicol 42 3 (2004) 273-276
42. Inadvertent misadministration of meningococcal conjugate vaccine-United States, June-August 2005. MMWR Morb Mortal Wkly Rep 2006;55(September (37)):1016-7.
43. Jean-Philippe P., Freedman A., Chang M.W., Steinberg S.P., Gershon A.A., LaRussa P.S., et al. Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction. Pediatrics 120 November (5) (2007) e1345-e1349
44. Forrey R.A., Pedersen C.A., and Schneider P.J. Interrater agreement with a standard scheme for classifying medication errors. Am J Health Syst Pharm 64 January (2) (2007) 175-181
45. Zhan C., Smith S.R., Keyes M.A., Hicks R.W., Cousins D.D., and Clancy C.M. How useful are voluntary medication error reports? The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf 34 January (1) (2008) 36-45
46. Leape L.L. Reporting of adverse events. N Engl J Med 347 November (20) (2002) 1633-1638