title: Immunisation errors reported to a vaccine advice service: intelligence to improve practice.
abstract: BACKGROUND
  The success of immunisation programmes depends on the quality with which they are administered. The Vaccine Advice for CliniCians Service (VACCSline) is an advice service to support immunisers and promote excellence in immunisation practice, through specialist guidance and local education, covering a catchment population of two million people. All enquiries are recorded onto a database and categorised. Vaccine error is selected when a vaccine has not been prepared or administered according to national recommendations or relevant expert guidance.
  
  
  METHODS
  All enquiries from 2009 to 2011, categorised on the VACCSline database as 'vaccine error' were analysed and subjected to a detailed free-text review.
  
  
  RESULTS
  Of 4301 enquiries, 158 (3.7%) concerned vaccine errors. The greatest frequency of errors, 145 (92.9%) concerned immunisations delivered in primary care services; 92% of all errors occurred during either vaccine selection and preparation or history checking and scheduling. Administration of the wrong vaccine was the most frequent error recorded in 33.3% of reports. A shared first letter of the vaccine name was noted to occur in 13 error reports in which the incorrect vaccine was inadvertently administered. Consultations involving pairs of siblings were associated with various errors in seven enquiries. Failure to revaccinate after spillage (seven reports) showed a widespread knowledge gap in this area.
  
  
  CONCLUSIONS
  Advice line enquiries provide intelligence to alert immunisers to the errors that are commonly reported and may serve to highlight processes that predispose to errors, thus informing immuniser training and updating.
authors.affiliation: Thames Valley Public Health England Centre, Chilton, Didcot OX11 0RQ, UK. sarah.lang@phe.gov.uk.
authors.forename: Sarah
authors.initials: S
authors.lastname: Lang
authors.affiliation: Thames Valley Public Health England Centre, Didcot, UK; Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Ford
authors.affiliation: Thames Valley Public Health England Centre, Didcot, UK; Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
authors.forename: Tessa
authors.initials: T
authors.lastname: John
authors.affiliation: Department of Paediatrics, University of Oxford, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Pollard
authors.affiliation: Thames Valley Public Health England Centre, Didcot, UK.
authors.forename: Noel D
authors.initials: ND
authors.lastname: McCarthy
mesh_terms: D004282:Documentation / Q000706:statistics & numerical data*; D006801:Humans; D008508:Medication Errors / Q000145:classification / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care; D014611:Vaccination / Q000706:statistics & numerical data*