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Monday, 12 March 2012

Immunization Error Incidents – shhhhh – don’t tell anyone they happen.

In 2004 (Canadian Adverse Events Study ), the Baker/Norton report was published that spoke to the size of the problem of medical error – the culmination of multiple health care processes that sometimes resulted in minor annoyances but occasionally in tragic outcomes.  They estimated one in 13 adult patients suffered an adverse event.  About one-quarter were due to medication errors. 

8 years later, sophisticated drug dispensing systems are the norm, and reducing adverse drug events have been promoted as one of the six initial Safer Health Care now initiatives Safer Healthcare Now (Medication Reconciliation).   Stacked up against the manufacturing industry, healthcare performs very poorly.   While manufacturing processes aim for zero defects – error rates of 0.3%-1.0% are relatively typical.

Canada had 386000 births in 2010/11.  Assuming about 95% get immunized, and the average male child now receives 14 injections and female receives 17.  Add to this at least one-third of all Canadians receive influenza vaccine.    Canada now provides about 6.5 Million vaccine injections a year (give or take 10% for some assumptions).

Applying the best manufacturing defect rates suggest we should see no less than 20,000 vaccine error incidents annually.  This would be about the order of magnitude for the number of medication error incidents (occurring at a rate close to 4.5% of admissions) .  On this concern, have you ever seen a good  local report in Canada that openly discusses vaccine error incidents for a local jurisdiction as part of vaccine quality control programming. (please correct us if you can send one to drphealth@gmail.com)   Based on what is currently reported, one would incorrectly assume an error rate more likely in the 0.01% range – seems pretty unlikely given the vaccine system problems we know exist through poor documentation, complex schedules, provider interpretation of paper based business rules, vaccine packaging that can be similar, client memories that are sometimes less than perfect etc...  

The financial implication is while we have seen hundreds of millions invested in safer patient care for medical purposes in the last decade.  We are only just going to field trials of a newer vaccine database to help case manage individuals, and this was driven more by preventing outbreaks than reducing immunizing incidents or tracking vaccine adverse events.

Why can we (or any vaccine system globally) not have the following:

1.       National database immunization registry accessible and interoperative with all points of health care so that vaccines can be provided at any health interaction? 
2.       Scanning technologies for vaccine documentation and charting (and reconciliation)
3.       No less than annual reports on adverse reactions to vaccines
4.       No less than annual reports on vaccine error incidents

A reader brought to our attention a technology innovation using smart phones to record influenza immunization  or other mass vaccination scenarios Smart phone use for vaccine documentation.   Once again perhaps local innovations will conquer and  proliferate.  

Then we will find ourselves asking the question why can’t we move information with the client from one place to the next?  

1 comment:

  1. Speaking of needles and errors...An elderly locum physician was covering for my F.P. and I was in to get my weekly allergy shot. I knew the locum and we were chatting when I noticed the size of the dose he was about to give me. The syringe was full to the brim.

    I had just moved up to a new vial of allergen solution the week before, and my FP had complained the week before of how hard it was to draw such a small dose. I waited my 20 minutes and had reacted with a few small hives and significant swelling that he checked, and commented that I'd be on the same dose for at least another week. Pretty great he did that, as I was able to question the locum on the dose. He reassured me it was accurate. I persisted. He was about to give me 100 times my scheduled dose.

    What if I wasn't a health care professional? What if my F.P. hadn't made the dose comment the week before? What if I had been distracted and hadn't noticed what the locum was about to give me?

    I didn't report him (my bad), but I did mention it to my FP when he was back.