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ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;20:1-4.
This newsletter series reports on 2 years of data collected during a national effort to collect vaccine administration errors. The first article summarizes information about the types of vaccine errors reported and why they occur. The second article discusses risks during vaccine use and offers recommendations to prevent them.
Tools/Toolkit > Measurement Tool/Indicator
Horsham, PA: Institute for Safe Medication Practices.
This reporting program collects data on errors and concerns associated with vaccines.
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
Mistakes in the use of vaccines can have both individual and public health implications. The first article of this series reviews the results from an analysis of reports submitted to a national error reporting system to track vaccine-related errors. The second article offers recommendations to help immunization and vaccination programs address product-, knowledge-, and practice-related factors that contribute to process weaknesses, including training, storage, and labeling strategies.
Journal Article > Study
Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013.
Hibbs BF, Moro PL, Lewis P, Miller ER, Shimabukuro TT. Vaccine. 2015;33:3171-3178.
Vaccination-related errors reported to the National Vaccine Adverse Event Reporting System grew from 10 in the year 2000 to 4324 in 2013, potentially due to the introduction of new vaccines, increasingly complex vaccination schedules, and changes in reporting practices. The most common errors were dispensing vaccines at an inappropriate schedule or administering expired or incorrectly stored vaccines. One-fourth of reported errors caused an adverse health event, with 8% of these resulting in serious harm.
Journal Article > Study
Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database.
Bundy DG, Shore AD, Morlock LL, Miller MR. Vaccine. 2009;27:3890-3896.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.
This article reports on an investigation into clusters of mistakes involving the misadministration of a vaccine.