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Case Report: Medical Error in Paediatric Vaccination

Abstract

Analysis and writing of this case study is undertaken by evidencing and observing the entire incident while working in Aga Khan Hospital, Pakistan and asking the questions from respective departments. We are discussing a medical error associated with a hospital setting in which the neonates are affected by the negligence of medical staff resulting in adverse drug reaction by routine vaccination for the prevention of TB. BCG vaccination is routinely administered to neonates in TB prevalent areas and TB endemic countries. This vaccination is not a part of routine immunization in developed countries. This case study is written when there was accidental administration of ONCO-BCG vaccine instead of neonatal vaccine which was 80 times more potent than usual neonatal vaccination. The main methodology of the study was observation of entire incident while working in inpatient pharmacy department and data was taken from article published in PubMed journal by AKUH pediatrics department doctors and students. The results showed developing of adverse effects (skin lesions, lymphadenopathy and coagulation derangement). None of the babies has actual clinical TB or disseminated disease. All are treated with ATT as a chemoprophylaxis and followed up for one year and cost was borne by hospital. The error was disclosed to the families as well. The main reason of this error was look alike vials as well as negligence of pharmacy and nursing staff to ignore the double checking of the vial before dispensing and administration. Chemoprophylaxis with ATT proved effective in this case. No mortality is observed.

Hira Jamil

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