Girl of eight weeks given MMR vaccine by mistake
Daily Mail, Dec 13, 2002
AN eight-week-old baby was accidentally given the MMR injection - a year before she was old enough to have it.
Shannon Whitter was taken to hospital after health centre staff realised a nurse had given her the wrong jab.
MMR, the injection against measles, mumps and rubella, has been the subject of controversy since doctors suggested links with autism and bowel disease, although the Government denies there are any dangers.
Shannon's ordeal began when her parents, Oeorge Whitter and Christine Fullen. took her to Bellevue health centre, in Edgbaston, Birmingham. 'She had the jabs in the afternoon, but later a GP from Bellevue rang and told us they were really sorry but a nurse had given her the MMR jab by mistake, said Mr Whitter, 43. Fortunately, staff at Birmingham Children's Hospital said Shannon was protected because she still had her mother's antibodies in her system.
“We hadn't even discussed whether we were going to give it to her or not. We didn't get a choice in the end,' said her father. The couple have to decide if Shannon is given the jab again in a year.
Dr Andrew Carson of Bellevue Medical Centre said: 'The practice nurse quickly noticed the error after administering the vaccine and this was reportede to the family soon afterwards.
Being open and honest defused a bad blunder
Pulse; Tonbridge; Jan 13, 2003;
Copyright CMP Information Ltd. Jan 13, 2003
MMR vaccine; DPT vaccine
Dr Andrew Carson examines the aftermath of a vaccine given in error
The child health clinic had been much like any other, apart from the fact that the regular nurse was away on an immunisation update course and her place had been taken by another practice nurse. The clinic finished just before evening surgery. Suddenly, the relative tranquillity of this interval was shattered by the appearance of the nurse in a state of some distress, come to inform me that she had inadvertently given an eight-week-old the MMR vaccine in place of the DPT and HiB.
Discussion with the nurse and health visitor ensued, and the health visitor agreed to contact the family as soon as possible. I did not believe there was any increased risk to the child from the MMR vaccine being given early, but checked this with public health officials and the manufacturers. Both sources confirmed my initial assessment.
Towards the end of evening surgery I heard from the parents, who expressed concern and anger. I apologised on behalf of the practice and reassured them that their child was not at any increased risk from the early administration of the vaccine. These points would need to be reiterated frequently over the coming days, at each contact with the parents.
Opportunity for discussion
I invited the parents to discuss things with me as soon as surgery had finished. The discussion was lengthy and covered their distress and concern over the fact their child had received a controversial vaccine without their consent. I felt my function at that time was to listen and be supportive without being defensive. The family have subsequently said that, although the incident should not have happened, they felt very supported through their anxieties by the actions of the practice team.
I concluded my interview with the parents by informing them about our complaints procedure and by giving them details of how I could be contacted personally at all times over the coming days. I contacted them later that night and early the following morning to check that the baby was well.
The following morning the sequence of events was reported to our primary care manager who immediately started a Serious Untoward Incident investigation. This involved interviewing all the parties involved, including the parents, to try to establish the cause of the incident and see what additional safety measures could be put in place before the next clinic. The PCT was also informed early in the day.
By late morning on day two we were informed that a relative of the baby had approached the press, and we were asked for a statement by a daily newspaper. After obtaining consent from the baby's parents, a press release was prepared in conjunction with the PCT. The media agency employed by the PCT was invaluable at this stage, fielding much press attention. Misreporting and misrepresentation made the front page in the local paper that afternoon. For example, it was reported that the baby had been rushed to hospital, which hadn't been the case at all.
This was followed by a request for an interview by the local television news. The media agency was again extremely helpful in preparing me for the questions.
Vaccinations as usual
We felt it was important to stress the support we were giving to the baby's family, the nurse involved, and the rest of the practice team. Furthermore, it was crucial to reinforce the importance of parents continuing to allow their children to be vaccinated in the usual way. The incident was, after all, a rare and isolated one that had not put the baby involved at any increased risk.
Subsequent activity revolved around accurate documentation and reporting of events surrounding the incident, as well as implementing new safety procedures and issuing a statement to our patients.
The MPS had been involved from an early stage and appeared happy with the way we had handled the situation.
We also sought advice on catching up with the DPT vaccine that had not been administered. Finally, the nurse involved had to go through a disciplinary hearing.
It was a frantic few days that involved a great deal of upset for everyone involved. But it was also a valuable learning experience and much good has come out of it. For example, we now plan to colour- code our vaccines for easy identification.
The nurse, along with the rest of the team, behaved with great honesty and integrity once the mistake had been discovered. This cannot be stressed too strongly. One hopes that aggressive press attention will never discourage individuals from admitting their mistakes.
I am convinced that our being open and honest helped defuse a difficult situation.
Andrew Carson is a GP in Birmingham
Practice candid over MMR error
Pulse; Tonbridge; Jan 6, 2003;
Copyright CMP Information Ltd. Jan 6, 2003
MMR vaccine; DTP vaccine
Dr Andrew Carson found openness was the best policy when his practice nurse accidentally gave an eight-week-old the MMR vaccine.
Dr Carson, a GP in Birmingham, commended the nurse for behaving 'extremely responsibly' by informing them immediately when she realised she had given MMR instead of DTP vaccine.
Packaging confusion could be to blame. Dr Carson said: 'Once the vial is taken out of the pack the name of the vaccine is actually obscured by the lot number and expiry date. But that is not to excuse what happened.'
Copyright: CMP Information Ltd.