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Tips on avoiding


when injecting


It is vital to ensure

that protocols for administering injections are reviewed regularly in view of the common errors that can occur, says Dr Karen Roberts of the MDU

Pneumococcal vaccine is due to be introduced to the routine child vaccination schedule this year for babies at 13 months. This will help to provide more protection against meningitis and septicaemia.

But with a growing number of inoculations and vaccinations being administered, it is important to ensure protocols for administering injections are reviewed regularly, bearing in mind the common injection errors that can occur.

In an MDU survey from 2004, 399 cases of alleged medication error were reported by its members over a seven-year period. Of these some 60 per cent (244 cases) involved vaccines. Injection errors also featured significantly in an MDU review of settled claims involving practice nurses in 2000 dating back over a five-year period.

The MDU settled 86 claims during this time of which nearly half involved procedures undertaken by nursing staff. Of these almost 25 per cent (19 claims) related to injection errors.

A common allegation is administration of vaccine to children without the authority of the parents. Several cases related to the combined MMR vaccine where parents had expressed a prior wish for the vaccine not to be given.

Take the example of the practice nurse running a busy routine immunisation clinic who saw a mother and child. The medical records were not immediately available but the practice nurse told the mother she was going to give routine immunisations.

After the nurse administered MMR, diphtheria/ tetanus and polio vaccinations to the child, the mother said in passing how relieved she was that the child had not had the MMR.

The practice nurse obtained the records and saw that the mother had expressed concern about MMR and had withheld her authority to administer it at a previous consultation. The practice explained the mistake to the parents, apologised and, recognising this as an adverse event, took steps to review its procedures to prevent a future recurrence.

In another case a mother brought her baby in for an MMR vaccination, having received notification of a recall via the Child Health Computer System. The practice nurse took the MMR vaccination from the fridge and checked it was the correct vaccine with another nurse.

The practice nurse checked the baby's identity and the recall card. The nurse did not check the patient's notes, where details of a previous MMR vaccination were recorded in the computerised record.

As the batch number had not been recorded on the practice computer, the fact that the baby had received the MMR vaccine already was not recorded by the health authority. As a result, the baby was given the vaccination twice in error. When the error was realised an explanation and apology was given immediately.

These examples highlight some of the common causes of errors seen by the MDU, particular with regards to vaccines. The MDU 2004 study found a number of consistent themes within the cases reported. These included:

·Inconsistency or failure to record that

parents have withheld authority to a

specific vaccine.

·A failure to check the records prior to

administration of the vaccine, relying on only a standardised initiation letter.

·A problem with the status of the

accompanying adult. There are many

instances where members of the family or other carers who do not have parental

responsibility are accompanying the child for vaccination. It is important that valid

authority is sought from an appropriate adult who has parental responsibility.

The MDU advises doctors that, prior to any injection, a full history should be taken from the patient or parent including all details of previous vaccines and any current medication. When administering injections to young children, appropriate authority should be obtained ­ from someone with parental responsibility ­ prior to administering the vaccine.

The fact approval has been given should be documented in the medical notes along with details of the proposed procedure, warnings of the risks involved, any side-effects and alternatives to the procedure.

All drugs should be checked prior to administration by the health care professional administering the drug, together with details of the drug, the mode and site of the injection. In addition, the batch number and expiry date should be documented.

Drugs should be stored at the manufacturers' recommended storage temperature in a refrigerator specifically designated for drug storage. A member of staff should take responsibility for regular routine checks to ensure the refrigerator is operating correctly at the correct temperature.

Records should be complete, legible and contemporaneous as they are an essential part of the continuing care of the patient and can also provide invaluable evidence in the event of a complaint or claim.

The GMC's guidance document Good Medical Practice (2001) advises doctors delegating care or treatment that they must be satisfied the person to whom they are delegating is competent to carry out the procedure or provide the therapy involved. Paragraph 46 states: 'You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient.'

Nurses who undertake clinical procedures should be fully trained, indemnified and competent to perform their duties in accordance with the requirements of their regulatory body, the Nursing and Midwifery Council.

They should adhere to an agreed, up-to-date protocol, which is signed by the GP and the practice nurse.

By ensuring robust arrangements are in place to check that consent or parental authority has been obtained and that the correct drug is being administered, injections errors can be avoided.

Karen Roberts is an MDU clinical risk manager

The cases mentioned are based on MDU files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

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