Vaccines with names that look and sound alike can lead to vaccination errors

Research Activities, February 2010, No. 354

When it comes to vaccinating children, nurses refer to the "5 rights" to ensure the right vaccine is given to the right patient in the right dose by the right route at the right time. David G. Bundy, M.D., M.P.H., and his colleagues at Johns Hopkins University used this convention to determine at what point these rights go wrong and result in vaccine errors for children. After studying 607 vaccine error reports, the researchers found that the wrong vaccines, times, and doses were at the heart of most errors, but wrong route and wrong patient errors were rare.

Vaccine names were the culprit for many of the wrong vaccine errors. For example, tetanus group vaccines, accounting for 36 percent of wrong vaccine errors, not only look alike (Td, Tdap, TDap, and DT), but they also have brand names that sound alike (Adacel® and Daptacel®).

Wrong time errors most often occurred with scheduled vaccines being given earlier or later than recommended for a child's age. The authors suggest that inadequate vaccination records may cause wrong time errors. They add that even electronic vaccination records may not be robust enough to track the 30 or more vaccinations U.S. children receive by the time they are 6 years old.

Technology, namely computerized provider order entry and prescription writing, may reduce wrong dose errors, which occur when the wrong volume or concentration of a vaccine is administered. For instance, doses of palivizumab, a vaccine to prevent lower respiratory tract infections, are based on a child's weight and resulted in nearly 60 percent of wrong dose errors. This study was funded in part by the Agency for Healthcare Research and Quality (HS16774).

See "Pediatric vaccination errors: Application of the '5 rights' framework to a national error reporting database," by Dr. Bundy, Andrew D. Shore, Ph.D., Laura L. Morlock, Ph.D., and Marlene R. Miller, M.D., in the June 2009 Vaccine 27(29), pp. 3890-3896.

Current as of February 2010
Internet Citation: Vaccines with names that look and sound alike can lead to vaccination errors: Research Activities, February 2010, No. 354. February 2010. Agency for Healthcare Research and Quality, Rockville, MD.