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Nurse Gives Baby Incorrect Vaccine

Deputy Health and Disability Commissioner Rose Wall today released a report finding a registered nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failure in her care of a baby being vaccinated.

At the time of these events, the baby was overdue for his six-week vaccinations. During a home visit, the nurse administered the wrong six-week vaccine to the baby.

Instead of the rotavirus vaccine, the nurse vaccinated the baby with Prevenar 13, a vaccine that is normally administered by injection for protection against pneumococcal disease. This was in addition to the PCV10 vaccine (another vaccine used for the protection against pneumococcal disease) meaning that the baby was essentially given the same vaccination twice on this day, and missed out on his rotavirus vaccine.

The day after the baby’s vaccinations, the nurse was alerted to a potential error. She failed to report it and attempted to cover up her mistake by making a second home visit to amend the records in the baby’s Well Child book. She also failed to communicate with the family about the mistake.

The Deputy Commissioner found by failing to identify and administer the correct vaccine to the baby, the nurse did not provide services with reasonable care and skill. By attempting to cover up her mistake, she failed to comply with her ethical and professional obligations.

"The nurse should have alerted the baby’s family to her mistake, and her failure to report it lead to a delay in the error being rectified," said Ms Wall.

"It also meant that the baby’s family were not alert to signs of possible reaction to the drug error in the young infant.

"Instead of owning up to her mistake, the nurse went to significant efforts in an attempt to cover up her error," she said.

The Deputy Commissioner recommended the nurse undertake training on documentation and safe administration of medications, and provide the baby’s family with a written apology.

She also recommended that the Nursing Council of New Zealand consider whether a review of the nurse’s competence and any further action is warranted. The nurse was also referred to the Director of Proceedings.

The full report on case 19HDC01647 is available on the HDC website.

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