Retrospective study of immunization errors reported in an online Information System.
Tânia Cristina Barboza, Rafael Alves Guimarães, Fernanda Raphael Escobar Gimenes and 1 others
PMID 32578753WHAT IT FOUND
Reported immunization errors in Goiás were mostly in infants, first doses, and intramuscular vaccines.
Most caused no adverse event, but wrong indication, dose interval, and technique were common. Check age, interval, vaccine identity, and injection technique.
Key findings
01Most reported immunization errors did not cause an adverse event: 90.6% were without AEFI and 9.4% were with AEFI.
02The commonest error types were inadequate indication (26.9%), inadequate interval between doses (18.2%), and administration technique error (14.2%).
03The reported incidence was 4.05 immunization errors per 100,000 doses applied, and 0.45 errors with AEFI per 100,000 doses.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
It used reported notifications, not a direct count of all errors, so the real error rate may be higher. Some records lacked route of administration and race/skin color, so those descriptions are incomplete. Reporting practice differed between institutions, so the numbers may reflect reporting culture as much as error frequency. It describes one Brazilian state during the study period, so it may not match local vaccination services. It does not test any intervention to prevent errors.
The easy way to misread this
Do not treat the reported incidence of 4.05 errors per 100,000 doses as the true error rate. The study used notifications only, and the authors state underreporting, missing data, and differences in reporting culture may underestimate the real magnitude.