Volume 27, Issue 29, Pages 3801-3926 (12 June 2009)
Pediatric vaccination errors: Application of the “5 Rights” framework to a national error reporting database
David G. Bundy, Andrew D. Shore, Laura L. Morlock, Marlene R. Miller
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 on these human factors.