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Incorrect vaccination given to child (15HDC01397)
Download Incorrect vaccination given to child (15HDC01397) (PDF 70Kb)
(15HDC01397, 20 June
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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