Program Errors in Taiwan’s Mass Immunizations againstPandemic A/H1N1

Po-Ju Chiu1, Wan-Ting Huang2, Song-En Huang2,3, Yi-Chien Chih1, Chang-Hsun Chen1

2010 Vol.26 NO.15

Correspondence Author： Po-Ju Chiu

Abstract：

On November 1, 2009, Taiwan launched a mass vaccination campaign against A/H1N1 pandemic. Because of the large quantity of vaccine doses to be administered, the number of program errors may also increase. We collected reports to the nationwide, voluntary error reporting system from November 1, 2009 through February 24, 2010. We analyzed reports to determine the types of errors and assess critical contributors to the error. From November 1, 2009 through February 24, 2010, 33 incidents of vaccination errors were reported. The reported errors included wrong vaccine (n=22), wrong dose (n=7), repeated vaccinations (n=2), and others (n=2). Inadequate staff competency and education, lack of quality process and risk management, and communication failures were key system elements contributing to reported errors. In the mass pandemic A/H1N1 vaccine campaign, program errors were associated with predictable/correctable human and systemic factors; efforts to decrease errors need to focus on provider education, computer support, and vaccine recipient flow optimization.