Özet:

Background: Pediatric vaccine errors may lead to patient harm, including unknown disease vulnerability requiring costly revaccination. Local Problem: Pediatric vaccine administration errors (expired and wrong vaccine) in a Federally Qualified Health Center prompted a root cause analysis. System and human factors issues were identified, including a variable and complex administration process; multiple administering staff (medical assistants, registered nurses, nurse practitioners); competency training gaps; and storage opportunities driving error. Methods: Using Plan-Do-Study-Act cycles, the administration process and storage system were improved. Interventions: A simplified and standardized pediatric vaccine administration process was implemented. Administering staff completed 10 hours of education and competency training. Audits with feedback were conducted to monitor process behaviors linked to achieving the five rights of medication administration. Results: Twenty-four audits were conducted over a six-month period after implementation to monitor steps in the process. Early post-implementation analysis revealed performance variability and additional improvement activities were deployed. Behaviors have improved over time and are nearing consistent performance and no reported vaccine errors. Conclusions: Continuous analysis and improvement are needed to sustain safe practice until behaviors to achieve the five rights are normalized and impact patient outcomes.

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