According to the Institute for Safe Medication Practices (ISMP), the number of accidental mix-ups of pediatric (DTaP) and adult (Tdap) vaccines used to immunize patients against diphtheria, tetanus, and pertussis (whooping cough) is alarming. The ISMP Medication Errors Reporting Program database contains hundreds of cases, and without a conscientious effort by medical professionals, the problem will get even worse.
The DTaP vaccine is formulated to provide initial immunization of pediatric patients starting at six weeks through six years of age. The upper case letters in DTaP correspond with higher doses of diphtheria and pertussis.
The Tdap vaccine is made up of tetanus toxoid, reduced diphtheria toxoid and pertussis antigen and is meant to be used as booster shots for older children, adolescents and adults. An adult who mistakenly gets the DTaP would not need to be revaccinated but would be more likely to have a sore arm at the vaccination site.
Infants and young children should get five doses of DTaP, one dose at each of the following ages: two, four, six, and 15-18 months and years four to six to adequately immunized them against diphtheria, tetanus and pertussis. Infants and young children who are improperly immunized with Tdap may not be adequately protected against diphtheria or pertussis, if exposed, and may become ill with the disease.
To prevent mix-ups, CAP's Risk Management & Patient Safety Department recommends the following precautions:
- Separate the pediatric and adult formulations in your storage area.
- Discuss and share this article with the employees who provide immunizations.
- Employ a "verification" and "time-out" process in your office. Have two people verify the proper vaccine is being used.
- Write the order for vaccines by brand name and not by vaccine abbreviations.
Reference: ISMP Medication Safety Alert
Authored by
Ann Whitehead, RN, JD
CAP Risk Management & Patient Safety Department
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.