Point-of-care Mixup: 1 Shot Turns Into 3
A 2-month-old boy brought in for a well-child visit was ordered the appropriate vaccinations, which included a combination vaccine for DTaP, Hib, and IPV. After administering the shots to the patient, the nurse realized she had given the DTaP vaccination alone, instead of the combination vaccine. Thus, the infant had to receive two additional injections. In the accompanying commentary, F. Ralph Berberich, MD, of East Bay Physicians Medical Group, discusses strategies to prevent errors and reduce pain associated with routine pediatric vaccinations.