Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS)
- PMID: 16711311
- DOI: 10.1097/01.smj.0000216513.73448.af
Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS)
Abstract
Background: A study was done to determine if the apparent medication errors found in the Vaccine Adverse Event Reporting System (VAERS) database are true errors, and if true errors are found, to determine what corrective action was taken. Furthermore, if a true error did not occur, we wanted to determine at what point the misinformation was entered into the system.
Methods: The VAERS database was searched for reports received between July 1, 2001 and June 30, 2002 which had either been classified as "error" or the word "error" appeared in the text of the report. The database was also searched for reports which indicated that the measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), diphtheria-tetanus-acellular pertussis (DTaP) or diphtheria-tetanus-pertussis-haemophilus (DTPH) vaccinations had been administered at an age outside of the usual recommendation.
Results: A total of 119 reports of possible errors were found. Follow-up was successful in 102 (86%) cases. Additional information obtained showed that 26 cases were actual medication errors. Seventy-six cases were not actual medication errors; 9 cases were physician decisions, 37 cases were data entry errors and 30 cases were reporter errors.
Conclusion: The nature of the actual errors was similar to those reported previously; wrong inoculum, improper interval, wrong route of administration, and overdose. Many errors could have been prevented by more attention to detail. Remedial action usually consisted of retraining. The new requirement that all medications be barcoded, purchasing products from different manufacturers and segregation of vials may help prevent vial confusion.
Similar articles
-
Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000-2013.Vaccine. 2015 Jun 22;33(28):3171-8. doi: 10.1016/j.vaccine.2015.05.006. Epub 2015 May 14. Vaccine. 2015. PMID: 25980429
-
Surveillance for safety after immunization: Vaccine Adverse Event Reporting System (VAERS)--United States, 1991-2001.MMWR Surveill Summ. 2003 Jan 24;52(1):1-24. MMWR Surveill Summ. 2003. PMID: 12825543
-
Adverse events after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine administered to adults 65 years of age and older reported to the Vaccine Adverse Event Reporting System (VAERS), 2005-2010.Vaccine. 2011 Nov 21;29(50):9404-8. doi: 10.1016/j.vaccine.2011.05.100. Epub 2011 Sep 13. Vaccine. 2011. PMID: 21920404
-
Live attenuated measles and mumps viral strain-containing vaccines and hearing loss: Vaccine Adverse Event Reporting System (VAERS), United States, 1990--2003.Vaccine. 2008 Feb 26;26(9):1166-72. doi: 10.1016/j.vaccine.2007.12.049. Epub 2008 Jan 22. Vaccine. 2008. PMID: 18255204 Review.
-
Elective termination of pregnancy after vaccination reported to the Vaccine Adverse Event Reporting System (VAERS): 1990-2006.Vaccine. 2008 May 2;26(19):2428-32. doi: 10.1016/j.vaccine.2008.02.052. Epub 2008 Mar 17. Vaccine. 2008. PMID: 18406499 Review.
Cited by 1 article
-
Evaluation of scanning 2D barcoded vaccines to improve data accuracy of vaccines administered.Vaccine. 2016 Nov 11;34(47):5802-5807. doi: 10.1016/j.vaccine.2016.09.052. Epub 2016 Oct 11. Vaccine. 2016. PMID: 27742219 Free PMC article.
MeSH terms
Substances
LinkOut - more resources
Full Text Sources
Medical