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At the heart of general practice since 1960

Being open and honest defused a bad blunder

Dr Andrew Carson examines the aftermath of a vaccine given in error

he child health clinic had been much like any other, apart from the fact that the regular nurse was away on an immunisation update course and her place had been taken by another practice nurse. The clinic finished just before evening surgery. Suddenly, the relative tranquillity of this interval was shattered by the appearance of the nurse in a state of some distress, come to inform me that she had inadvertently given an eight-week-old the MMR vaccine in place of the DPT and HiB.

Discussion with the nurse and health visitor ensued, and the health visitor agreed to contact the family as soon as possible. I did not believe there was any increased risk to the child from the MMR vaccine being given early, but checked this with public health officials and the manufacturers. Both sources confirmed my initial assessment.

Towards the end of evening surgery I heard from the parents, who expressed concern and anger. I apologised on behalf of the practice and reassured them that their child was not at any increased risk from the early administration of the vaccine. These points would need to be reiterated frequently over the coming days, at each contact with the parents.

Opportunity for discussion

I invited the parents to discuss things with me as soon as surgery had finished. The discussion was lengthy and covered their distress and concern over the fact their child had received a controversial vaccine without their consent. I felt my function at that time was to listen and be supportive without being defensive. The family have subsequently said that, although the incident should not have happened, they felt very supported through their anxieties by the actions of the practice team.

I concluded my interview with the parents by informing them about our complaints procedure and by giving them details of how I could be contacted personally at all times over the coming days. I contacted them later that night and early the following morning to check that the baby was well.

The following morning the sequence of events was reported to our primary care manager who immediately started a Serious Untoward Incident investigation. This involved interviewing all the parties involved, including the parents, to try to establish the cause of the incident and see what additional safety measures could be put in place before the next clinic. The PCT was also informed early in the day.

By late morning on day two we were informed that a relative of the baby had approached the press, and we were asked for a statement by a daily newspaper. After obtaining consent from the baby's parents, a press release was prepared in conjunction with the PCT. The media agency employed by the PCT was invaluable at this stage, fielding much press attention. Misreporting and misrepresentation made the front page in the local paper that afternoon. For example, it was reported that the baby had been rushed to hospital, which hadn't been the case at all.

This was followed by a request for an interview by the local television news. The media agency was again extremely helpful in preparing me for the questions.

Vaccinations as usual

We felt it was important to stress the support we were giving to the baby's family, the nurse involved, and the rest of the practice team. Furthermore, it was crucial to reinforce the importance of parents continuing to allow their children to be vaccinated in the usual way. The incident was, after all, a rare and isolated one that had not put the baby involved at any increased risk.

Subsequent activity revolved around accurate documentation and reporting of events surrounding the incident, as well as implementing new safety procedures and issuing a statement to our patients.

The MPS had been involved from an early stage and appeared happy with the way we had handled the situation.

We also sought advice on catching up with the DPT vaccine that had not been administered. Finally, the nurse involved had to go through a disciplinary hearing.

It was a frantic few days that involved a great deal of upset for everyone involved. But it was also a valuable learning experience and much good has come out of it. For example, we now plan to colour-code our vaccines for easy identification.

The nurse, along with the rest of the team, behaved with great honesty and integrity once the mistake had been discovered. This cannot be stressed too strongly. One hopes that aggressive press attention will never discourage individuals from admitting their mistakes.

I am convinced that our being open and honest helped defuse a difficult situation.

The nurse behaved with great integrity once the

mistake had been made~

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