Vaccine Administration Errors: The Wrong Route

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Millions of vaccines are administered yearly in the US in a variety of settings by individuals with very different levels of training. Mistakes happen. Let's look at one category as reported through the Vaccine Adverse Event Reporting System (VAERS), wrong route. Other categories are wrong vaccine, wrong timing interval, wrong storage, and wrong age indication among many others.

The wrong route

Vaccines can be given by a variety of routes: IM, sub-Q, oral, intradermal, and intranasal. As you might imagine, every possible permutation has happened. The most difficult mistake for me to understand is when an oral vaccine is given IM.

The two most commonly used oral vaccines are Rotarix and Rotateq, both given routinely to infants under 6 months of age. Rotateq comes in a plastic tube with a screw off top revealing a small opening to squirt in the baby's mouth. In no way does it resemble a vaccine vial. To administer this IM, one would need to screw off the top and stick a needle down the tiny hole to withdraw the vaccine (reading glasses will be needed by the old folks doing this). Rotarix does have a vial with a lyophilized powder that needs to be mixed with a diluent in a syringe and the mixture is then supposed to be given orally. A needle will not fit on the end of this syringe. Despite these barriers, between 2006-2013, 39 cases of IM administration were reported-33 with Rotarix and 6 with Rotateq.About half of these reports mentioned an adverse event: the two most common were ir rritability and injection site inflammation.

Despite these barriers, between 2006-2013, 39 cases of IM administration were reported-33 with Rotarix and 6 with Rotateq.

If your medical assistant or nurse reported doing this to a 2-month-old, your initial reaction might be to fire her or him. But, if you do this, you will never again hear about a vaccine error from your staff. Instead, you need to compliment the person for bringing this error to your attention so things can be fixed.

  ^► The first thing to do is give the vaccine properly by mouth.

  ^► The second is to discuss the error with the patient.

  ^► The third thing to do is figure out how this happened (what training did this individual receive) and fix things so it never happens again.

  ^► Fourth, you should report the error through the VAERS system and notify your malpractice carrier.

An easier mistake to understand might be when a SQ injection is given IM or vice versa. Per the PI, MMR, varicella, zoster, and MMRV should be given SQ.

What do you do in this scenario? Your nurse comes to you and tells you that she got her syringes mixed up and gave an MMR into the muscle and the Prevnar via the SQ route. Prevnar per its PI should be given IM.

You tell her:

A. Despite the error, the CDC considers both does valid and nothing needs to be repeated.

B.  Repeat both doses via the proper route today.

C.  Have the patient return in 4 weeks and give both doses properly at that time.

D. Repeat the Prevnar today, but the MMR is considered valid by the CDC.

Please leave your answer below.

Please click here for correct answer and discussion

Images above:
Left ©Marius Pirvu/Shutterstock.com; right ©Dmitry Naumov/Shutterstock.com 
 

The correct answer is: A. Despite the error, the CDC considers both does valid and nothing needs to be repeated.

The CDC considers the dose valid for all SQ vaccines if they are given IM. So the MMR is OK. Certain IM vaccines are considered valid if given SQ and some will need to be repeated. The IM vaccines that need a repeat dose on the same day if given SQ are Hep B, HPV, and rabies, so the Prevnar is valid.

Do you have a story of a vaccine delivered via the wrong route? Use the comment section below and tell us how you handled it and steps you took to avoid a repetition.

Resources

  ^► From www.immunize.org,a one page sheet listing route, dose, site, and needle size for vaccines

  ^► A PowerPoint presentation on vaccine errors and prevention, given by the CDC: Vaccine Administration Frequent Errors and Prevention Strategies. National Adult and Influenza Immunization Summit – 5/12/2015