Vaccine med error

[LactivistRN]

GUYS. I need someone to calm me down. I've never felt so horrible and sad in my entire life.

So I work on a mother baby unit, we do well babies and postpartum care. I've been there about 7 months and it's my first RN job. Over in L&D, they do the vitamin K shot and erythromycin ointment on the babies. It's pretty controversial to refuse those newborn meds.

Anyways, over on mother baby, we give the hepB vaccine. It's a booster that immunizes the infant before the pediatrician gives the series. I'd say like 10% of my patients refuse it. Routinely, we give it with the bath at 8 hours or with the labs at 36 hours. Babies generally go to the nursery for labs.

You either say "yes" and fill out the consent form or you refuse it and there's no refusal documentation besides the unfiled paper SBAR we use for handoffs. The vaccine is always prescribed in the MAR for EVERY infant. I.e. no electronic barriers whatsoever to giving it unless it's already been given.

So this mom I had the other day didn't want her baby to get any vaccines. She refused her own mmr, flu shot, etc.

well I was doing labs on the baby and I knew I had 2 babies who still needed their hepB and we've been super busy trying to get everyone home on time. Long story short, I mixed up the babies in my head and gave this baby the vaccine, and the parents didn't want it. I immediately realized after I checked the SBAR. I told my charge, we did a report, we told the parents etc.

do you think this is like a "totally fired" scenario or a "learn from it" scenario?

[brownbook]

If you are fired thank your lucky stars that you no longer work for a toxic hospital.

Seldom, if ever, should a nurse or doctor be fired for making an error.

The events leading up to the error, what protocol, what checks, what system, what algorithm, was in place that caused the error are reviewed to find out what went wrong and how to prevent it. NOT what one human being did wrong.

You are my hero for immediately telling the charge nurse and the parents.

[iluvivt, BSN, RN]

Once a mother refuses perhaps an electronic barrier needs to be in place then when you would have scanned the armband it would have not let you administer it.I would come up with a better system and be instrumental in making sure this does not happen to anyone else.At least no harm came to the infant although some may disagree.

[Jory, MSN, APRN, CNM]

Once a mother refuses perhaps an electronic barrier needs to be in place then when you would have scanned the armband it would have not let you administer it.I would come up with a better system and be instrumental in making sure this does not happen to anyone else.At least no harm came to the infant although some may disagree.

Agreed. At my hospital we don't give any of the eyes/thighs/B until baby has a medication band.