A 10-year-old child from India presented to his pediatrician’soffice for a school physical. The child had no past medicalhistory, was in excellent health, and all immunizations were up todate except for Hepatitis B. The physician discussed the issuesaround vaccination with the patient’s father and obtained consent.The nurse drew up the vaccine and the physician administered it.After administration, the physician went to record the lot numberand discovered that a dose of vaccine for Hepatitis A had beengiven instead of Hepatitis B.
Without hesitation, the physician informed the father that thewrong vaccine had mistakenly been given to the boy. He explainedthe usual indications for Hepatitis A vaccination and emphasizedthat this vaccine would not bring any harm to the boy and may evenprotect him from illness in the future. He suggested that the boystill receive the Hepatitis B vaccine. The father became extremelyangry. He refused to allow further vaccination and proceeded toreport the incident to the clinic administrator.
After the vaccine incident, the physician in this case feltresponsible for the loss of trust and the missed opportunity toadminister an important vaccine to a child. 2. What actions shouldthe medical team take to understand why this error occurred? Whatchanges can they make to ensure that this error does not occuragain