Retrospective study of immunization errors reported in an online Information System

Abstract

<jats:p> 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.</jats:p>

Incidência de erros de imunização em Minas Gerais: estudo transversal, 2015-2019

“…According to the rules of the National Immunization Program ( Programa Nacional de Imunizações - PNI), immunization errors may cause reduction or lack of the expected effect of vaccines, in addition to adverse events following immunization (AEFI). 3 These errors may also have a negative impact on the population, interfering in the follow-up of the vaccination schedule, reducing vaccination coverage rates and jeopardizing the control of vaccine-preventable diseases, 4 - 6 in addition to generating direct and indirect costs to health services. 7 - 8 …”

“…In the last ten years, the international 5 , 9 - 10 and national literature 4 , 6 have pointed to an increase in notifications of immunization errors. A study conducted between 2001 and 2016, aiming to describe the characteristics of vaccination errors using a European database, identified an increase in the number of notifications of vaccine errors, from 0.4%, in 2001, to 4% in 2016.…”

“…4 In the state of Goiás, the overall incidence rate of errors was 4.1/100,000 doses administered, and the highest incidence rates were related to the human rabies vaccine, the human papillomavirus vaccine and the triple viral vaccine; the incidence rate of errors regarding AEFI was 0.45/100,000 doses administered. 6 In the state of Minas Gerais, a study conducted between 2015 and 2019, aimed at analyzing immunization errors in pregnant women, according to the absence and presence of AEFI, found an incidence of 2.07/100,000 doses administered, showing errors and some adverse events. 11 …”

Analysis of immunization errors in pregnant women

“…A study carried out in the state of Goiás, with data from the IS-PNI/IS-AEFI, confirms these findings, since it revealed a higher ratio of IE related to the vaccine against measles, mumps, rubella (attenuated) (MMR) (15,4%) and yellow fever (12.0%) (20) too. This can be explained by failures in the prescription and/or indication of the immunobiological, type of immunobiological used, and error in the evaluation of contraindications or prescriptions (20) . The importance of a multidisciplinary team with up-to-date knowledge about the recommended vaccination schedule for this public is highlighted, especially that of the prenatal nurse, to change this scenario.…”

The leading role of Nursing in the vaccination against COVID-19 versus questionable irregularities a descriptive-exploratory study

“…It is noteworthy, in another way, that despite the careful and important social role performed by Nursing and the entire effort to carry out mass vaccination of the population, this professional collective is not exempt/free from making mistakes. Indeed, immunization errors are a reality to be faced by the health systems and by the Nursing workforce (14) .…”