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Incorrect vaccination given to child (15HDC01397)

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(15HDC01397, 20 June 2016)

Registered nurse ~ Medical centre ~ Vaccination ~ Administration error ~ Right 4(1)

A woman took her son, aged 23 months, to a medical centre for a vaccination. The woman discussed the vaccination with a registered nurse and requested that her son receive the Infanrix®-IPV vaccination instead of the Infanrix®-hexa vaccination listed on the New Zealand National Immunisation Schedule.

The registered nurse failed to take the time to listen to the woman properly and understand that the child was to receive the Infanrix®-IPV vaccination rather than the Infanrix®-hexa vaccination, and administered Infanrix®-hexa to the child.

The woman identified the vaccination administration error almost two weeks later and reported it to the medical centre.

By failing to administer the correct vaccination to the child, the registered nurse failed to provide the child with services with reasonable care and skill and breached Right 4(1).

Overall, the medical centre had appropriate processes in place to support safe and accurate immunisation practices. The registered nurse's error in administering the incorrect vaccination to the child was an individual clinical error. Accordingly, the medical centre did not breach the Code.

The Deputy Commissioner recommended that the registered nurse undertake training in effective communication with consumers and that the medical centre train its staff on the new procedures in its internal immunisation protocol. The medical centre has advised that this training has been completed. 

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