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Learning from our mistake has helped us move forward

After a recent vaccination mishap, Dr Andrew Carson's practice asked some searching questions

Several weeks ago we had the misfortune to experience a critical incident at the practice in which an infant was mistakenly given the MMR vaccination instead of DTP and Hib.

The incident itself has been discussed earlier in Pulse (January 13, 2003). I want now to indicate what we learned from the episode, what action we have taken to try to prevent such a thing happening again, and what questions have been raised. We think the episode has helped us to move forward.

The mistake was treated as a Serious Untoward Incident and triggered an investigation of events leading up to the error, including interviews with parents and staff involved. These interviews were cross-referenced with each other to ensure as accurate an account of events as possible. Any potential discrepancies were clarified through further discussions with interviewees.

Incident reporting and handling the media

This event was reported to the PCT and upwards to public health at the directorate of health and social care, via the strategic health authority.

The Medical Protection Society was also kept informed and involved throughout.

Early in the proceedings, a member of the family went to the local press, which ran the story inaccurately.

We have subsequently asked ourselves:

lHow prepared were we, as a team, to handle an incident of this nature?

lHow do we deal with the needs of the patients involved while also supporting the staff and team?

lAre we adequately prepared to face a media onslaught?

lIs there a case for a practice developing a positive relationship with the local media so that incidents are more fairly reported in future?

lDo we need specific training in handling the media?

lWould it be helpful to have a script for a 'dry run' Serious Untoward Incident so that everybody becomes familiar it?

This practice plans to prepare a formal package for training purposes, which we aim to make available to other practices.

Checking on the administration of immunisations

In secondary care, many injections will be checked by two people prior to administration. By contrast, in primary care this is often left to the individual member of staff involved.

We have therefore asked ourselves:

lCould we improve the checking of immunisations prior to administration?

lShould we show parents the vaccines before administering them?

lIf we involve parents, should we colour-code the vaccines and the immunisation schedule to assist those who have difficulty with English?

lShould we simply leave the vials next to the parents so that they can choose whether to examine the labels or not?

lShould we ensure that the vials are only discarded after the immunisation has been administered, so that they can be rechecked if necessary?

lDuring the immunisation session, should we store the vaccines in insulated boxes, one for each vaccine, arranged in chronological order of the immunisation schedule, so that the 'cold chain' is maintained without the need for constant trips to the drugs fridge?

In the event we have decided in future to leave vials next to the parents, to colour-code the vials and to use insulated boxes in chronological order.

Questions we asked ourselves about staff training

The nurse involved was standing in for the regular nurse who does our immunisations. She was relatively new to our team but had been working previously at a senior level in a local hospital.

She had never made an error like this before and acted in a highly responsible way by reporting the mistake straightaway. She had gone through a comprehensive induction period and had observed and administered vaccinations under supervision.

Questions we asked ourselves included:

lHow do we assess the effectiveness of staff induction and training?

lIs it enough to follow the

pattern of 'see one, do one, teach one'?

lShould there be some more formal assessment of training to ensure it is effective?

lIf so, how frequently should staff undergo such an assessment process?

Our practice is now planning to implement regular reassessment of all clinical staff.

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