Pediatric Vaccine Administration

Sustaining an Improved Process in a Primary Care Setting

  • Marianne L. Durham, DNP, RN University of Illinois at Chicago
  • Ines Didovic, DNP, RN University of Illinois at Chicago
  • Monica J. Gingell, DNP, RN University of Illinois at Chicago
Keywords: vaccine error, quality improvement, sustainability, patient safety

Abstract

Background: Pediatric vaccine errors may lead to patient harm, including unknown disease vulnerability requiring costly revaccination.

Local Problem: Pediatric vaccine administration errors (expired and wrong vaccine) in a Federally Qualified Health Center prompted a root cause analysis. System and human factors issues were identified, including a variable and complex administration process; multiple administering staff (medical assistants, registered nurses, nurse practitioners); competency training gaps; and storage opportunities driving error.

Methods: Using Plan-Do-Study-Act cycles, the administration process and storage system were improved.

Interventions: A simplified and standardized pediatric vaccine administration process was implemented. Administering staff completed 10 hours of education and competency training. Audits with feedback were conducted to monitor process behaviors linked to achieving the five rights of medication administration.

Results: Twenty-four audits were conducted over a six-month period after implementation to monitor steps in the process. Early post-implementation analysis revealed performance variability and additional improvement activities were deployed. Behaviors have improved over time and are nearing consistent performance and no reported vaccine errors.
Conclusions: Continuous analysis and improvement are needed to sustain safe practice until behaviors to achieve the five rights are normalized and impact patient outcomes.

Author Biographies

Marianne L. Durham, DNP, RN, University of Illinois at Chicago

Marianne L. Durham, DNP, RN, is a clinical assistant professor in the Department of Health Systems Science at the College of Nursing at the University of Illinois at Chicago. Her scholarship interests include quality improvement and patient safety in multiple settings.

Ines Didovic, DNP, RN, University of Illinois at Chicago

Ines Didovic, DNP, RN, is a registered nurse in a neonatal intensive care unit and earned a Doctor of Nursing Practice degree with a family nurse practitioner population focus from the College of Nursing at the University of Illinois at Chicago.

Monica J. Gingell, DNP, RN, University of Illinois at Chicago

Monica J. Gingell, DNP, RN, is a registered nurse in a pulmonary step-down unit and earned a Doctor of Nursing Practice degree with a family nurse practitioner population focus from the College of Nursing at the University of Illinois at Chicago.

References

Greenwood B. The Contribution of Vaccination to Global Health: Past, Present and Future. Philos Trans R Soc Lond B Biol Sci. 2014;369(1645):20130433. doi:10.1098/rstb.2013.0433. Accessed September 15, 2019.

Jhaveri R. Vaccines. ClinTher. 2017;39(8):1516-1518. doi:10.1016/j.clinthera.2017.07.008. Accessed September 15, 2019.

Paparella SF. Vaccine Errors: Understanding the Risks and the Responsibilities for Public Safety. J Emerg Nurs. 2015;41(5):428-430. doi:10.1016/j.jen.2015.05.010

World Health Organization. Global Immunization Data, 2014.https://www.who.int/immunization/monitoring_surveillance/global_immunization_data.pdf?ua=1. 2014. Accessed November 21, 2019.

Sofer D. New Immunization Initiatives Show Promise. Am J Nurs. 2017;117(7):14. doi: 10.1097/01.NAJ.0000520928.57149.97. Accessed November 21, 2019.

Bundy DG, Shore AD, Morlock LL, Miller MR. Pediatric Vaccination Errors: Application of the “5 Rights” Framework to a National Error Reporting Database. Vaccine. 2009;27(29):3890-3896. doi:10.1016/j.vaccine.2009.04.005. Accessed September 15, 2019.

Institute for Safe Medication Practices. ISMP National Vaccine Errors Reporting Program: One in Three Vaccine Errors Associated With Age-Related Factors, 2016.https://www.ismp.org/resources/ismp-national-vaccine-errors-reporting-program-one-three-vaccine-errors-associated-age. Published July 28, 2016. Accessed November 20, 2019.

Sarkar U. Tip of the Iceberg. BMJ Qual Saf. 2016;25(7):477–479. doi: 1136/bmjqs-2015-005006. Accessed November 10, 2019.

Institute for Safe Medication Practices. ISMP National Vaccine Errors Reporting Program-2017 Analysis (Part 1): Vaccine Errors Continue With Little Change, 2018. https://www.ismp.org/resources/ismp-national-vaccine-errors-reporting-program-2017-analysis-part-i-vaccine-errors. Published June 14, 2018. Accessed October 18, 2019.

Reed L, Tarini BA, Andreae MC. Vaccine Administration Error Rates at a Large Academic Medical Center and Its Affiliated Clinics – Familiarity Matters. Vaccine. 2019;5390-5396. https://doi.org/10.1016/j.vaccine.2019.07.027. Accessed November 17, 2019.

Lang S, Ford KJ, John T, Pollard AJ, McCarthy ND. Immunisation Errors Reported to a Vaccine Advice Service: Intelligence to Improve Practice. Qual Prim Care 2014; 22(3):139-46; PMID:24865341. Accessed September 10, 2019.

Durham ML, Suhayda R, Normand P, Jankiewicz A, Fogg L. Reducing Medication Administration Errors in Acute and Critical Care: Multifaceted Pilot Program Targeting RN Awareness and Behaviors. J Nurs Adm, 2016. 46(2), 75-81. doi: 10.1097/nna.0000000000000299

Reason J. Human Error. New York: Cambridge University Press; 1990.

Agency for Healthcare Research and Quality. Systems Approach, Patient Safety Primer, 2019. https://psnet.ahrq.gov/primers/primer/21.

Kohn L, Corrigan J, Donaldson M. To Err Is Human. Washington, D.C.: National Academy Press; 2000.

Charles R, Vallée J, Tissot C, Lucht F, Botelho-Nevers E. Vaccination Errors in GeneralPractice: Creation of A Preventive Checklist Based on a Multimodal Analysis of Declared Errors. Family Practice. 2016;33(4):432-438. doi:10.1093/fampra/cmw026. Accessed November 15, 2019.

Koenig KM, Bozic KJ. Orthopaedic Healthcare Worldwide: The Role of Standardization in Improving Outcomes. Clin Orthop Relat Res. 2015;473(11):3360–3363. doi:10.1007/s11999-015-4492-6

Neuspiel DR, Taylor MM. Reducing the Risk of Harm From Medication Errors in Children.Health Serv Insights. 2013;(6):47-59. doi:10.4137/hsi.s10454

Institute for Safe Medication Practices. The Five Rights: A Destination Without a Map. https://www.ismp.org/resources/five-rights-destination-without-map. Published January 25, 2007. Accessed January 30, 2020

Centers for Disease Control and Prevention. Vaccine Administration, 2018. https://www.cdc.gov/vaccines/hcp/admin/admin-protocols.html. Published May 16, 2018. Accessed November 15, 2019.

Lennox L, Maher L, Reed J. Navigating the Sustainability Landscape: A Systematic Review of Sustainability Approaches in Healthcare. Implement Sci. 2018;13(1). doi:10.1186/s13012-017-0707-4. Accessed November 10, 2019.

Bernstein M, Hou J, Weizman A et al. Quality Improvement Primer Series: How to Sustain a Quality Improvement Effort. Clin Gastroenterol Hepato. 2016;14(10):1371-1375. doi:10.1016/j.cgh.2016.05.019. Accessed July 13, 2019.

Mate KS, Rakover, J. 4 Steps to Sustaining Improvement in Health Care. Harv Bus Rev. https://hbr.org/2016/11/4-steps-to-sustaining-improvement-in-health-care. Published April 5, 2016. Accessed November 19, 2019.

Institute for Healthcare Improvement. Quality Improvement Project Management, 2018.http://www.ihi.org/resources/Pages/Tools/QI-Project-Management.aspx. Published 2018. Accessed November 15, 2019.

Ament S, Gillissen F, Moser A et al. Factors Associated With Sustainability of 2 Quality Improvement Programs After Achieving Early Implementation Success: A Qualitative Case Study. J Eval Clin Pract. 2017;23(6):1135-1143. doi: 10.1111/jep.12735. Accessed April 14, 2019.

Hayes CW, Goldmann D. Highly Adoptable Improvement: A Practical Model and Toolkit to Address Adoptability and Sustainability of Quality Improvement Initiatives. 2018;44(3):155-163. Jt Comm J Qual Saf. doi: 10.1016/j.jcjq.2017.09.005. Accessed November 21, 2019.

Fleiszer A, Semenic S, Ritchie J, Richer M, Denis J. Nursing Unit Leaders’ Influence on the Long-Term Sustainability of Evidence-Based Practice Improvements. J Nurs Manag. 2015;24(3):309-318. doi:10.1111/jonm.12320. Accessed November 15, 2019.

Stone S, Lee H, Sharek P. Perceived Factors Associated With Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Jt Comm J Qual Saf. 2016;42(7):309-AP4. doi:10.1016/s1553-7250(16)42042-8. Accessed April 1, 2019.

Langley GJ, Moen R, Nolan KM, et al. Changes That Result in Improvement. In: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass; 2009:15–25.

Reed JE, Card AJ. The Problem With Plan-Do-Study-Act Cycles. BJM Qual Saf. 2016; 25(3):147-152. doi: 10.1136/bmjqs-2015-005076. Accessed November 20, 2019.

Immunization Action Coalition. Skills Checklist for Vaccine Administration, 2017. http://www.immunize.org/catg.d/p7010.pdf. Published October 2017. Accessed June 26, 2019.

Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement, IHI White Paper, 2016. Cambridge, Massachusetts: Institute for Healthcare Improvement. Accessed April 14, 2019.

Teal box with title.
Published
2020-06-17
How to Cite
Durham, M., Didovic, I., & Gingell, M. (2020). Pediatric Vaccine Administration: Sustaining an Improved Process in a Primary Care Setting. Patient Safety , 2(2), 12. https://doi.org/10.33940/med/2020.6.5
Section
Original Research and Articles
Bookmark and Share