Authors

1Rocío Fernández Urrusuno, 2Ana Gavilán Lara, 3María Espinosa Bosch, 3José Miguel Cruces Jiménez, 3Carmen Beltrán Calvo

Position

¹Técnico de Salud del Medicamento. Servicio de Farmacia. Distrito Sanitario Aljarafe.²Técnico de Laboratorio. Servicio de Farmacia. Distrito Sanitario Aljarafe.³Servicio de Farmacia. Distrito Sanitario Aljarafe.

Contact address

Servicio de Farmacia. Distrito Sanitario Aljarafe. Avda. de las Americas, s/n. 41927 Mairena del Aljarafe, Sevilla.

Contact email: rocio.fernández.sspa@juntadeandalucia.es

Abstract

Objective: to identify errors in the administration of vaccines as well as errors that could be a result of similar packaging, in a district of the Andalusian Health Service in 2007.  The results of this study were used in both an internal and external dissemination strategy.   
Material and method: descriptive study in the Health District of Aljarafe (Seville) of the Andalusian Health Service (AHS).  Information regarding vaccination errors reported in 2007 was gathered.  Similarities in the names and labelling of the different vaccines available in the centres were analyzed.  
Results: eight real errors were detected after the administration of the 23-valent antipneumococcic vaccine instead of the flu vaccine.  These errors were due to the highly similar labelling of both types of vaccine.  15 other situations which could lead to errors related with design and name were identified.  Internal dissemination was carried out via the distribution of documentation to those in charge of vaccine management in the Area and to the Andalusian Health Service and by means of informative sessions for the Nursing team in these centres.  Vaccination errors were reported to the Institute for the Safe Use of Drugs, which in turn informed the Spanish Drug and Healthcare Products Agency and laboratories which manufactured the vaccines involved.  
Conclusions: vaccines are a group of drugs presenting a high probability of leading to administration errors due to their similarities in name and labelling.  Until measures are adopted to clearly differentiate them, professionals are required to be careful in the correct identification of drug packages to avoid administration
errors.  

Keywords:

vaccination; vaccination errors; patient safety; drug administration; Primary CareCommunity Nursing

Versión en Español

Título:

Errores vacunales y situaciones que pueden conducir a errores en Atención Primaria de salud