Pediatric vaccination errors: Application of the "5 Rights" framework to a national error reporting database

被引：37
作者：
Bundy, David G. [1 ,2 ]
Shore, Andrew D. [3 ]
Morlock, Laura L. [3 ]
Miller, Marlene R. [1 ,2 ,3 ]
机构：
[1] Johns Hopkins Univ, Sch Med, Dept Pediat, Baltimore, MD 21287 USA
[2] Johns Hopkins Univ, Sch Med, Qual & Safety Res Grp, Baltimore, MD 21287 USA
[3] Johns Hopkins Bloomberg Sch Publ Hlth, Dept Hlth Policy & Management, Baltimore, MD USA
来源：
VACCINE | 2009年 / 27卷 / 29期
基金：
美国医疗保健研究与质量局;
关键词：
Medication errors; Vaccines; Ambulatory care; MEDICATION ERRORS; SAFETY; TABLES; TESTS; CARE;
D O I：
10.1016/j.vaccine.2009.04.005
中图分类号：
R392 [医学免疫学]; Q939.91 [免疫学];
学科分类号：
100102 ;
摘要：
Little is known about vaccination errors. We analyzed 607 outpatient pediatric vaccination error reports from MEDMARX, a nationwide, voluntary medication error reporting system, occurring from 2003 to 2006. We used the "5 Rights" framework (right vaccine, time, dose, route, and patient) to determine whether vaccination error types were predictable. We found that "wrong vaccine" errors were more common among look-alike/sound-alike groups than among vaccines with no look-alike/sound-alike group. Scheduled vaccines were more often involved in "wrong time" errors than seasonal and intermittent vaccines. "Wrong dose" errors were more common for vaccines whose dose is weight-based and age-based than for vaccines whose dose is uniform. "Wrong route" and "wrong patient" errors were rare. In this largest-ever analysis of pediatric vaccination errors, error types were associated with predictable vaccine-related human factors challenges. Efforts to reduce pediatric vaccination errors should focus Oil these human factors. (C) 2009 Elsevier Ltd. All rights reserved.
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收藏
页码：3890 / 3896
页数：7
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