Childhood immunisations: Routine or risky?

While administering vaccinations and immunisations is considered to be a routine task, things can and do go wrong, leaving the general practice nurse (GPN) open to a complaint or claim. Here Medical Protection provides practical tips to help GPNs practise safely when administering childhood immunisations

CASE SCENARIO

Three-month-old baby James was brought to the surgery by his grandmother for his immunisations. It was a particularly busy Friday afternoon and not a regular baby clinic session.

Baby James’ grandmother informed Nurse K that he had missed his last appointment as his mother has a needle phobia and was too upset to bring him in. Nurse K vaguely recalled having an earlier conversation with the mother about the immunisation schedule, but didn’t arrange for her to sign a consent form at the time as she assumed that she would personally bring James in for his immunisations. There was also nothing recorded in James’ notes about this conversation.

As Nurse K was unsure about whether she could administer James’ immunisations without his mother’s expressed consent, she did not proceed and explained to the grandmother that the mother must bring him herself.

The grandmother became very angry, as she had taken time off work to bring him in, and stormed out of the surgery. The following week the practice manager received a written letter of complaint.

While administering vaccinations and immunisations is considered to be a routine task, the case scenario above is an example of how issues can arise. It is therefore important to ensure that you are suitably trained, work within your competence and keep up to date with current guidelines, such as the UK Immunisation Schedule.¹

IMMUNISATION PROTOCOLS

All practices should have an immunisation protocol. Protocols specify the procurement, storage and safe administration of vaccines and define areas of responsibility.

A comprehensive immunisation protocol should contain specific details and requirements relating to:

• The UK Immunisation Schedule
• Obtaining consent
• Confirming patient details
• Checking vaccines
• Patient Group Directions (PGDs)
• Essential training for those administering vaccines, and when training should be updated
• How nurses will be supervised
• Availability of emergency equipment
• Vaccine storage
• Incident reporting procedures.

OBTAINING CONSENT

Whenever a child presents for an immunisation, you are required to ensure that consent is in place and has been discussed with a person who has parental responsibility for that child.

However, recent changes to the Green Book mean that the person with parental responsibility does not necessarily need to be present at the time the immunisation is actually administered.¹ Children may now be brought in for immunisation by a person without parental responsibility, such as a grandparent or child-minder. There is no requirement for such arrangements to be made in writing; however, you must be satisfied that the person with parental responsibility has consented in advance to the immunisation.

If you have any doubt, the immunisation should not be administered until you are certain there is consent. Similarly, if there is any indication that there may be a disagreement between those who have parental responsibility for the child, then the immunisation should not be carried out until you are certain that the dispute has been resolved.

DOCUMENTING CONSENT

While there is no legal requirement for immunisation consent to be in writing (for example, for a consent form to be signed), it is important to record in the patient’s notes if and when consent has been discussed and obtained.¹ This is vital given the recent changes to the Green Book as it is the responsibility of the nurse who is administering the immunisation to ensure that consent is in place. It is also particularly important to document if there is any disagreement between those with parental responsibility for the child.

Reflecting on the above points and considering the case scenario, Nurse K could have possibly avoided the situation if she had had a practice protocol available to her when originally speaking with James’ mother. She would have been able to refer to the document to verify her specific responsibilities, including: to discuss what immunisations were to be given to James, obtain consent, and document this in his records.

CHECKING PROCEDURES

Prior to administering any vaccination, you should always follow correct checking procedures, beginning by confirming the patient’s full name, address and date of birth. It is also important to check whether the child has had any previous reactions to vaccines, that the child is fit to receive an immunisation, the agreed injection site and the child’s immunisation schedule.

The vaccines should then be checked. While it would be ideal to have a colleague to assist with this process and ‘double check’ the vaccine labels and expiry dates, this is not always possible. It is therefore good practice to ask the parent/guardian to check the vaccine with you. This not only enables the parent/guardian to feel involved in the procedure and to fully understand what their child is being given, it also provides an opportunity for them to discuss any concerns they may have. Because of this, it is a good idea only to take the vaccines out of the fridge after discussing with the parent/guardian which ones will be administered (rather than preparing the vaccines in advance).

RECORD KEEPING

Detailed and contemporaneous medical records are essential for the continuity of care of your patients. Ensure that the name, batch number and expiry date of each vaccine administered is recorded, as well as the injection site used. It is also important to make a note of who brought the child in for the immunisation and whether information leaflets were given.

STAFF TRAINING

Practice nurses must recognise and work within the limits of their competence.² As you are accountable for the tasks you undertake, it is important that you are competent and trained to administer vaccines. According to the UK Immunisation Schedule, this includes a minimum of two days for basic training in immunisation, as well as annual updates on anaphylaxis and CPR.¹

Emergency drugs and equipment must be available in any practice that administers immunisations, so you and your colleagues should also be trained to administer and operate these too.

VACCINE STORAGE

Safe vaccine storage and handling is essential to ensure that the cold chain is maintained from delivery and storage through to patient administration, in accordance with guidance in the Green Book.¹

Practices should therefore have appropriate procedures in place to ensure cold chain compliance. For example:

• Vaccines should be stored in a refrigerator in an organised way and be well labelled. Those with similar names or packaging should not be stored next to each other.
• Ideally, practices should have two vaccine fridges in order to keep paediatric and adult vaccines separate. If this is not possible, paediatric and adult vaccines should be clearly labelled according to the schedules and stored in separate designated sections of the fridge.
• The minimum, maximum and actual temperature of the refrigerator should be recorded daily, using at least one thermometer that is independent of mains power (so temperatures can still be recorded in the event of electricity loss).¹ Entries should be signed by the staff member who takes the reading, and kept for a year. Thermometers should also be calibrated monthly to confirm accuracy.³
• Regular vaccine stock control and a stock information system will help to ensure sufficient stock is available, rotated regularly and keep track of expiry dates.
• Avoid over-packed refrigerators, as this can lead to poor air flow and the potential freezing of stock.
• Keep a record of destroyed vaccines.

INCIDENT REPORTING PROCEDURES

Reflecting on practice is now a mandatory requirement for revalidation with the Nurse and Midwifery Council, and practices should therefore implement significant event analysis (SEA) meetings as a learning tool after every adverse event.⁴ Such meetings can provide the opportunity to investigate incidents thoroughly, encourage open discussions with staff involved, identify areas to improve patient safety, support the staff involved, consider learning and training needs, and feed findings back to the patient or their family.

It would be a good idea for Nurse K, for example, to conduct a SEA and write it up as part of her revalidation portfolio.

CHILDHOOD IMMUNISATION CLINICS

Holding dedicated immunisation clinics can improve efficiencies when administering childhood immunisations and may also help to reduce the risks of errors. If you are considering implementing dedicated clinics at your practice, ensure that the time allocated reflects the complexity of the UK Immunisation Schedule and that individual appointment times are sufficient to allow you to work safely and deliver quality patient care.

KEY LEARNING POINTS

• Adhering to practice protocols can help practice nurses to overcome potential risks.
• The UK Immunisation Schedule for children is now extremely complicated and practice nurses who undertake this task must be familiar with their requirements and keep up-to-date.
• It is the responsibility of the practice nurse who administers the immunisation to ensure that consent is in place.
• Recent changes to consent requirements in the Green Book now mean that the person with parental responsibility does not necessarily need to be present at the time the immunisation is given.
• There is no legal requirement for consent for immunisations to be in writing, but it is vital to record in the patient’s notes if and when consent is obtained.

REFERENCES

1. The UK immunisation schedule (2015), The routine immunisation schedule, at:

https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

2. Nursing and Midwifery Council (2015), The code: Professional standards of practice and behaviour for nurses and midwives, at:

https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

3. Care Quality Commission, Nigel’s Surgery 17: Vaccine Storage and Fridges in GP Practices, at:

http://www.cqc.org.uk/content/nigels-surgery-17-vaccine-storage-and-fridges-gp-practices

4. Nursing and Midwifery Council, Revalidation, at:

http://revalidation.nmc.org.uk/