Incidents
Presented by Aline Marron
Immunisation & Screening Coordinator
NHS England
September 2014
Aims of the session
• To raise awareness about Immunisation incidents.
• To raise awareness of the process for reporting
immunisation incidents to the Screening & Immunisation
(Public Health England)
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Immunisation Incidents
• What is a vaccination incident?
• Why report incidents
• Incidents and the role of the Immunisation & Screening Team
(PHE).
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Incidents
• Cold chain incidents
- vaccines stored at optimal range +2 to 8 degrees
celsius – licensure requirement.
- degredation of vaccines if stored outside of
recommended range.
- Loss of potency may result in suboptimal
response.
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Cold chain incidents
- vaccines stored at optimal range
vaccines given out of schedule, vaccine not
+2• Examples;
to
8
degrees
age appropriate, incorrect vaccine given, expired
vaccine
celsius – licensure requirement.
• Immunisation
& Screening
team
provide advice
and
degredation
of
vaccines
if
stored
sign post to other sources of information if required –
HPU, GP,
outside
ofScreening & Immunisation lead.
• Reporting may indicate trends i.e. training.
recommended range.
- Loss of potency may result in
suboptimal
response.
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Cold chain incidents
• Requires multidisciplinary risk assessment
- Immunisation & Screening Team (PHE DDT
Area Team)
- Medicines Optimising Service
- Vaccine manufacturer.
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Cold Chain incidents
• Report to;
Immunisation & Screening team at
ddtscreen.imms@nhs.net
Tel. 01138251600
• Local Reporting
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Cold Chain incidents
• Impact on service provision due to unavailability of
vaccines.
• Potential of suboptimal response to a vaccine
used outside of the cold chain
recommendations
• Time spent recalling to inform and possibly
revaccinating patients
• Cost – cost of vaccine and time
• Loss of confidence in service
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Cold Chain Incidents
• Due to mechanical or human error.
- cold chain disruption – fridge failure
- Loss of power – fridge unplugged.
- Power cut.
Building work.
- Fridge door not closed securely.
- Vaccines not placed in fridge after receipt.
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Immunisation Incidents
‘It is never acceptable to be in the position of
having to tell individuals that they may not be
protected by the vaccines they have received in
good faith as a result of human error’
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Cold chain incidents
• Minimize risk by;
• Identifying a member of the Pharmacy team to receive the vaccines and
place in fridge soon after delivery.
• Record the fridge temperature daily – morning and evening. Reset the
temperature – 3 R’s read, record, reset.
• Fridge hard wired into wall – no plug to dislodge.
• Lock fridge door – reduces risk of door being left open.
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Incident reporting process
• Pharmacy must inform the Immunisation and Screening
team of all incidents involving vaccines
• Pharmacy complete incident report and return.
• Immunisation & Screening Team audit reports and identify
trends and learning
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Useful information
• HPA Incident Guidance
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1267551139589
• Green Book
https://www.gov.uk/government/organisations/public-healthengland/series/immunisation-against-infectious-disease-the-green-book
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How to contact us
• Vaccine enquiry line 01138 251 600
• ddtscreen.imms@nhs.net
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