Background: Vaccine-related errors have been the most highly reported preventable patient harm throughout our medical group. The existing hierarchical leadership model throughout the medical group prevented frontline clinical staff from being empowered to make changes in their practice.

Purpose: The purpose of this project was to decrease vaccine-related errors using a shared governance model. Secondary gains of this project included increased caregiver satisfaction and frontline clinical staff being empowered to work to the top of their licensure.

Methods: For this project, we employed a shared governance model, creating the vaccine quality council to reduce vaccine related errors. Council membership consisted of frontline registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs) and is facilitated by the director of nursing and quality. This council structure was unique in that the frontline staff were empowered to “own” this initiative and make needed practice changes across the medical group based on evidence-based practice (EBP) standards.

The vaccine quality council developed a formal vaccine standardization process encompassing both primary care and specialty clinics. This standardization included a color code system to differentiate between vaccines for children and clinic-stocked vaccines, standard refrigerator setup, and standard job aids, as well as an independent verification process (peer check).

Education was done with all clinics, and audits were completed to ensure compliance. Additionally, to decrease variation, we standardized the vaccine products that are purchased across all clinics, eliminating products that were at higher risk for error.

The second phase of the process involved creating and implementing evidence-based vaccine protocols for RNs, LPNs and MAs. This process allowed caregivers at all levels to safely work at the top of their licensure, while offloading work previously performed by our providers.

Results: Over the last year, our frontline staff took ownership of vaccine practice, standardized the vaccine administration process, and implemented top of licensure protocols for all caregivers. We implemented the standardization process on 10/1/18, and since that time, we have had ZERO vaccine errors. The process not only decreased vaccine errors by 25% since the inception of the council, but also increased vaccine compliance by 2.4%.

Conclusions: Using a shared governance model to develop vaccine standardization has been highly successful. Our rate of vaccine errors has declined and frontline staff are proud of the work they have accomplished and have begun participating in state level vaccine discussion.

Future considerations: We are currently expanding our focus to addressing the issue of vaccine hesitancy (delay or refusal to accept vaccines), as this is a huge barrier to patients receiving vaccinations in our area. With evidence-based practice changes to support reduction in vaccine hesitancy, we are confident we will further increase vaccination compliance and provide additional improvements to care delivery for our patients.

Renee DaPrano BSN, RN, CPN

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