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


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.


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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.
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