Implementation of a Vaccine Error Reduction Quality Improvement Project in the Ambulatory Care Setting

Purpose: The most recent biannual report of vaccination errors from The Institute for Safe Medication Practices (ISMP), released on December 4, 2019, revealed that of the 1,143 events submitted, most errors reached the patient and occurred in medical clinics, physician practices, hospital (ambulatory care) and public health immunization clinics. The most common types of errors included wrong vaccine administered, wrong timing, extra dose given, and expired vaccine administered. About one-third of the extra doses given involved failure to check a patient’s vaccine history. More than one-half of the errors involving a wrong vaccine administered were due to similarities in product names, abbreviations, or packaging. The purpose of this quality improvement project was to reduce patient harm caused by vaccine administration errors in the ambulatory care setting.

Methods: Using our hospital’s event reporting system, MIDAS®, an increase in medication errors related to vaccines in ambulatory care physician practices was observed in late 2019. A vaccine checklist tool was created by the medication safety officer in collaboration with the ambulatory care practice council, consisting of registered nurses and medical assistants, to encourage an independent double check of the five rights of medication administration in addition to vaccine-related requirements. The checklist was piloted in July 2020 in five practices to obtain feedback regarding effectiveness and content. The final version was distributed to all primary care practices in the community health system with instructions for use in December 2020. Data was collected pre-checklist implementation from December 2019 to November 2020 and for post-implementation December 2020 to November 2021. This study is exempt from Institutional Board Review.

Results: N/A

Conclusions: N/A