Retrospective study of immunization errors reported in an online Information System.

Tânia Cristina Barboza,Rafael Alves Guimarães,Ana Elisa Bauer De Camargo Silva,Fernanda Raphael Escobar Gimenes

doi:10.1590/1518-8345.3343.3303

Abstract

Objective:to analyze the immunization errors reported in an online Information System.Method:retrospective study conducted with data from the Adverse Event Following Immunization Surveillance Information System. Immunization errors were analyzed with respect to demographic characteristics and the vaccination process. Frequencies and error incidence rates have been calculated. Binomial and chi-square tests were used to verify differences in the proportions of the variables.Results:501 errors were analyzed, the majority involving routine doses (92.6%), without Adverse Event Following Immunization (90.6%) and in children under five years old (55.7%). The most frequent types of errors were inadequacy in the indication of the immunobiological (26.9%), inadequate interval between doses (18.2%) and error in the administration technique (14.2%). The overall error incidence rate was 4.05/100,000 doses applied; the highest incidences of routine vaccines were for human rabies vaccine, human papillomavirus and triple viral; the incidence rate of errors with Adverse Events Following Immunization was 0.45/100,000 doses applied.Conclusion:it was found that immunization errors are a reality to be faced by the health systems, but they are amenable to prevention through interventions such as the adoption of protocols, checklists and permanent education in health.

Highlights

Immunization is a key component of the efforts made by the World Health Organization (WHO) to achieve the United Nations’ third Sustainable Development objective by 2030, which is to ensure a healthy life, promote wellbeing to be for all, at all ages, by reducing the infant and maternal mortality rate, from communicable and non-communicable diseases, including ensuring access to safe and quality vaccines(1).In the last few decades, the number of vaccinepreventable diseases has almost doubled and, to that end, the number of vaccine doses has increased for children and adults(2)
There was a higher proportion of immunization errors (IE) without adverse events following immunization (AEFI) than with AEFI (90.6% versus 9.4%; p-value
The results reported in the international literature reveal divergent data regarding the magnitude of the AEFI followed by IE

Summary

Introduction

In the last few decades, the number of vaccinepreventable diseases has almost doubled and, to that end, the number of vaccine doses has increased for children and adults(2). With the increase in the number of doses applied, the potential for immunization errors (IE) has increased globally(2). Despite advances in immunization surveillance systems worldwide, IE are often underreported(2). The IE can be conceptualized as any preventable events arising from the inappropriate use of vaccines, which may be related to professional practice and the imprudent use of immunobiologicals, which, outside the norms and appropriate techniques, can lead to negative impacts, such as inadequate immune protection, increased costs for health services, reduction confidence and potential injuries of health system users(3). The IE may cause adverse events following immunization (AEFI) and result in severe harms to the users(4-6)

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Discussion

Conclusion