Vaccine administration error (VAE)
VAE can occur as a result of errors in vaccine preparation, handling, storage or administration and can be associated with immunisation error-related reactions. Identification and follow-up of vaccine administration errors can identify and correct immunisation error-related reactions in a timely manner.
It is responsibility of the immunisation provider to manage VAE and seek advice from the local public health unit (PHU) if required. VAE resulting in a suspected adverse event following immunisation (AEFI) must be reported to the PHU. VAEs that pose a safety risk to the patient must be reported to the PHU and Therapeutic Goods Administration (TGA) via the National AEFI reporting form.
For instance, if Trumenba, a meningococcal B vaccine (registered for use in children aged 10 years and over) is dispensed and subsequently administered inadvertently to children aged less than 10 years, it will be considered a VAE. The provider is required to report the VAE to the PHU and TGA by completing the National AEFI report form and submitting to the PHU and TGA.
Further information about AEFI and VAE is available on NSW Health webpages at AEFIs and VAEs.
To reduce the risk of VAEs, always remember to follow AIH – Preparing for vaccination and the 7 rights of vaccine administration.
1) Right person/patient
2) Right vaccine/diluent
3) Right time
4) Right dosage
5) Right route, needle length and technique
6) Right injection site
7) Right documentation
RSV vaccine administration errors
NCIRS resource on clinical guidance on RSV immunisation product administration errors
COVID-19 vaccine administration errors
ATAGI guidelines on the management of a range of possible vaccine administration errors, including when a replacement (repeat) dose is recommended.
General advice on vaccine errors
- Advice relating to patient
- Open disclosure of the incident to the patient/parents of the patient.
- Inform patient of any expected side effects and possible remedies to help with side effects.
- Arrange follow up appointment for patient with GP – mainly as a health check, but also to maintaining the GP/patient relationship.
- Give the Patient/Parents HCCC contact details in case they want to report a complaint:
- Advice relating to practice
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- Usual incident reporting process within the practice
- Inform the practice Insurer
- Review practice policies/process to avoid error in future
- Clinical advice
- Send patient to Emergency Department if patient clinically unwell
- Contact NSWISS if clinical advice is required (eg revaccination advice)
- For accidental overdose see below.
- Reporting
Accidental overdose
- If an accidental overdose occurs, it is recommended to observe vital signs and, if symptomatic, to treat the symptoms. There are no specific overdose symptoms to be aware of.
- Follow the above Advice on Vaccine Errors – This error must be recorded through your normal jurisdictional medication error reporting systems.
- For more information, the Poisons Information Centre may be contacted on 131 126.
