Errors Associated with Influenza Vaccine Preparation and Administration

Abstract

In the interests of safe vaccination, it is important to recognize in advance the errors occurring in vaccination and to devise suitable countermeasures. However, there are many unclear aspects of circumstances associated with minor errors in manual drug preparation procedures, which may represent a blind spot in efforts to improve the vaccination process. In response, we investigated errors occurring in influenza vaccination from October 2017 to February 2018, including near misses during drug preparation.

Valid responses were received from 101 doctors and nurses. The total number of errors was 562. Among these, 81.8% (311/380) of doctor errors and 77.5% (141/182) of nurse errors occurred during drug preparation, most of which appeared to be near misses. However, there were cases in which the response after the error occurred was inappropriate, which led to the error being transmitted unmitigated to the vaccinees. Furthermore, there were cases in which errors occurred that had the potential to result in health damage to the vaccinees, but no explanation was given to the vaccinees and their families. Additionally, there were cases where the error was not reported to any authority inside or outside the hospital. There were 48 cases of needle stick injuries to health care professionals.

The findings of this investigation suggested that improvement of the manual skills of health care professionals and the creation of an environment that made errors difficult to commit would be effective in the prevention of errors in drug preparation. Moreover, to prevent health damage to vaccinees, we concluded that it was important to identify easily occurring errors and to actively review each process, including appropriate methods of response after an error has occurred.