Top 10 Common Medication Errors-Drug #10: Vaccine

Medication errors in the pediatric population occur in both the inpatient and outpatient settings. In fact, pediatric medication errors occur in the latter setting at a rate of about 16% of cases.¹

Many potential medication errors may occur. In this series, I focus on 10 errors that are seen frequently in outpatient clinics. In previous articles, I focused on common errors associated with infant acetaminophen,² insulin,³ ceftriaxone,⁴ hydralazine and hydoxzyine,⁵ amoxicillin/clavulanic acid,⁶ ketorolac,⁷ ciprofloxacin,⁸ carbamazepine,⁹ and clonidine.¹⁰Medication Error #10: Vaccine
A 4-month-old boy (weight, 6 kg) came into the clinic for routine vaccinations. One of the vaccinations he received was ActHIB^®. The clinician meant to use this product to vaccinate the patient against Haemophilus influenzae type B only. The nurse went to get the product from the refrigerator and mixed it with both NaCl 0.9% and the other diluent that was in the product’s box.

What is the problem here?

Discussion
Some practices use ActHIB^® to vaccinate patients against H influenzae type B only¹¹; however, ActHIB^® may be used in 2 different ways, depending on the diluent added. If only immunization against H influenzae is intended, the product should be reconstituted with NaCl 0.9%. There also is a diluent that comes with the product that contains DTP, which would provide additional immunization against diphtheria, tetanus toxoids, and pertussis.¹²

In this case, the nurse diluted the product with both NaCl 0.9% and the other diluent. Thus, the patient received extra coverage for DTP because he also would have gotten the diphtheria, tetanus, acellular pertussis (DTaP) vaccine separately (eg, Infanrix^®).

This error actually happens more often than one would think. To prevent this mistake, the staff should have a better understanding of the vaccine and procedure of mixing. If the clinic desires to use ActHIB^® for H influenzae immunization only, they should take out the other diluent that contains DTP from the box. Also, the place where the vaccines are stored should have clear labeling and identification of the products, especially at a place where both pediatric and adult patients are seen. In this environment, in fact, adult and pediatric vaccines should be stored in separate refrigerators to avoid confusion.

This error could have been prevented if the staff knew that ActHIB^® should be diluted with NaCl 0.9% if only immunization against H influenzae is intended.

References
1. Kaushal R, Goldmann DA, Keohane CA, et al. Adverse drug events in pediatric outpatients. Ambul Pediatr. 2007;7:383-389.
2. So J. Top 10 common medication errors-and how to avoid them: Drug #1: acetaminophen. September 19, 2011.
3. So J. Top 10 common medication errors-and how to avoid them: Drug #2: insulin. October 18, 2012.
4. So J. Top 10 common medication errors-and how to avoid them: Drug #3: ceftriaxone. November 28, 2012.
5. So J. Top 10 common medication errors-and how to avoid them: Drug #4: hydroxyzine and hydralazine. December 28, 2012.
6. So J. Top 10 common medication errors-and how to avoid them: Drug #5: amoxicillin/clavulanic acid. February 1, 2013.
7. So J. Top 10 common medication errors-and how to avoid them: Drug #6: ketorolac. February 27, 2013.
8. So J. Top 10 common medication errors-and how to avoid them: Drug #7: ciprofloxacin. April 2, 2013.
9. So J. Top 10 common medication errors-and how to avoid them: Drug #8: carbamazepine. April 29, 2013.
10. So J. Top 10 common medication errors-and how to avoid them: Drug #9: clonidine. May 21, 2013.
11. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 18th ed. Hudson, Ohio: Lexi-Comp; 2011.
12. Package insert. ActHIB^®. Accessed June 10, 2013.