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  • 1.  Vaccine Errors - staff accountability

    Posted 01-09-2025 16:08

    Hi all - wondering how you handle addressing vaccine errors in your clinics? 

    We have done training, and retraining, and have updated protocols, require double checks, etc - when they happen do you immediately jump to disciplinary action? Write up? Warning? 

    Do you have a different process for an eligibility or documentation error vs an actual administration error? Does anyone have a formal process or anything they'd be willing to share? 

    Thanks! 



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    Keri Urquhart MPH BSN RN
    Covenant Community Care- FQHC
    Detroit MI
    (586) 215-3448
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  • 2.  RE: Vaccine Errors - staff accountability

    Posted 01-09-2025 18:06

    Hello Keri,

    Our organization has implemented a new process. Depending on the error, our education team will assign a CBT to review either the clinic-administered medication (for sites that do not administer vaccines) workflow or medication administration workflow (for sites that administer non-vaccine medications and vaccines. There is a knowledge check with this and an attestation that the staff sign and give to their manager for their employee folder. For a second medication error, the education team will provide on-site remediation. Any additional errors the staff person may have, HR will get involved. 

    Thank you,

     

    J.J. Peacock, MSN-Ed., RN, AMB-BC

    Nursing Professional Development Generalist

    Sentara Ambulatory Services Division

     

    Office: 434-654-4529

    Email: SJPEACOC@sentara.com | SASDClinEduTeam@sentara.com

    590 Peter Jefferson Parkway, Suite 323, Charlottesville, VA 22911

     

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  • 3.  RE: Vaccine Errors - staff accountability

    Posted 01-10-2025 07:22
    Good Morning,

    When we had recurrent issues across multiple staff members we completed an FMEA to understand where the system issues were that we could fix. If there are challenges with individual staff members and failure to pay attention to detail, then disciplinary action must occur to hold the person accountable and ensure patient safety.

    Amy
    Sent from my iPhone


    Original Message


  • 4.  RE: Vaccine Errors - staff accountability

    Posted 01-10-2025 09:25

    What is the root cause of the problem? Ask 'Why' 5 times.

    While clinicians are held accountable for adhering to protocols and policies, threat of disciplinary action for a human error does nothing to prevent errors, and discourages reporting of them.



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    Leslie McDowell ANP-BC DNP RN
    Northwest AHEC/Wake Forest Univ Sch of Med
    Winston Salem NC
    (336) 972-7852
    ANP-BC DNP RN
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    Original Message


  • 5.  RE: Vaccine Errors - staff accountability

    Posted 01-10-2025 10:24

    Hi Keri!

    event reporting and correcting errors is always more effective when addressed in a non-punitive, cause-solution approach. Using punitive measures usually makes people less likely to report an error because they're afraid of being punished. Of course, gross negligence needs to be addressed properly, but in most cases a root-cause analysis is the best approach. In our clinic when we have an error, the person who made the error fills out a SERS report, they get assistance from management/leadership if needed on completing the form, following up with a clinician to investigate if there is a risk of harm or actual harm, and informing the patient. Once that portion is completed, the staff member and leadership discuss the error, how it happened, and work together to come up with solutions to prevent themselves or others from making a similar error in the future. Without naming/blaming, we review errors in our huddles and things to be mindful of. Using a systems and solutions oriented approach has resulted in low error rates and creative solutions for our team, and often solutions that end up being adopted by other clinics or departments based on that success. I can't remember who exactly came up with this approach, but I know many healthcare organizations have adopted it (I think it originally came from a manufacturing company, airplanes?). Best of luck!



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    Heather Perkins BSN, RN, ANB-BC
    Kaiser Permanente Northwest
    Vancouver WA
    (360) 241-1178
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    Original Message


  • 6.  RE: Vaccine Errors - staff accountability

    Posted 01-10-2025 13:00

    Several years ago our organization adopted "Just Culture", which follows standard algorithms for addressing errors and at-risk behaviors (including repetitive human error or duty to follow procedural rules). This type of standardized approach and guidance has been helpful for us as leaders.



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    Elizabeth Misjuns, MSN, RN, CEN
    Chief Nursing Officer
    Centra Medical Group
    Lynchburg, VA
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    Original Message


  • 7.  RE: Vaccine Errors - staff accountability

    Posted 01-11-2025 07:10

    I'm curious as to which staff members are more likely to have these vaccine errors: MA's, LPN's or RN's. Or is it an equal mix? 




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