Quality Improvement Project:

Wrong Shot Disclosure

Nicole Charter,
Megan Isaacson,
Kristina Pedroza
Cyrena Spencer
Background
● 10 year old child came in for school physical
◦ No past Medical History, was in excellent health, needed a Hep B vaccine

● The nurse went to draw up the vaccine in which doctor administered

◦ The doctor went over all the possible side effects of the vaccine and obtained consent

● After administration doctor went to record lot number and realized gave Hep A
vaccine, not Hep B
◦ Doctor tried to calmly explain to the father the mistake and that Hep A is another good shot to have
◦ Father was angry and refused an other vaccines (doctor wanted to administer Hep B)

(The Wrong Shot, n.d.)

 Manpower Methods
Staff not
working well Need to read the virals
together more carefully/ follow six
rights. Need more than one
Overworked bin to store vaccines
staff in fridge

Incorrect
vaccination
Document the lot number Vaccination not
administered
prior to administration clearly labeled
Have an additional
Different color vials
medical worker double
and/or labels
check

Machines Material
(The Wrong Shot, n.d.)
Root Cause Analysis
● There was no policy in place that required the
individual that pulled the medication to administer
the medication. Nor was there adequate training
on how to correctly administer medication (ie. six
rights). The gap in training and protocol led to an
adverse event.
(The Wrong Shot, n.d.; VA, 2015)
Actions to prevent further occurrence
● All medication rooms will be a silent space and will have a large poster near the
computer with the words “Silent Space!”. (Weak)
○ Warning in order to reduce distraction.

● A policy will be put in place that will require the individual that pulls the
medication to administer the medication. (Weak)
○ Policy and training.

(The Wrong Shot, n.d.; VA, 2015)

Actions to prevent further occurrence

● Require nurses to co-sign the medication log for vaccinations. (Strong)

○ Standardized process

● All medication systems will require six rights of medication administration prior
to giving the medication. (Strong)
○ Right patient, right drug, right dose, right time, right route, documentation.
■ Standardized process

(The Wrong Shot, n.d.; VA, 2015)

Outcome Measures
● Numerator: 100 percent of medication and vaccines will be safely
administered
● Denominator - 100 percent of medication/vaccination administered on the
unit
● Threshold - 100 percent of patients will receive the correct
medication/vaccine
● Date/time frame - immediately after training is conducted on the unit

*Outcome goal: zero medication/vaccination administration errors!

(The Wrong Shot, n.d.; VA, 2015)
Outcome Measures Type
● Adverse Event Outcome:
◦ Immediately after training is conducted, all staff will perform
each of the medication rights, verify patient’s allergies and
contraindications, lot numbers on vaccines, and only
administer medication personally drawn up 100% of the time.

(The Wrong Shot, n.d.; VA, 2015)

Stakeholder Analysis
Internal Stakeholders External Stakeholders
● Patient ● Insurance company
● Patient’s father and ● Professional
family Organizations
● Physician ● Unions
● Nurse ● Local nursing school
● Pediatricians office ● City Chamber of
● Clinical Administrator Commerce

(Marquis & Huston, 2015)

 Force Field Analysis
Driving Forces Restraining Forces
● Healthcare providers desire to ● Fear of repercussions
do no harm ● Fear of litigation
● Healthcare providers desire to ● Causing harm
provide quality care ● Comfortable disclosing mistake
● Institutions desire to improving
error disclosure
● Healthcare provider empathy
for patient

Strategies to mitigate restraining forces: Disclosure gap, empathic communication,

address healthcare providers emotional needs
(Marquis & Huston, 2015)
References
Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing: Theory and application (8th ed.).

Philadelphia, PA: Lippincott Williams & Wilkins.

The wrong shot: error disclosure (AHRQ). (n.d.). Retrieved from

http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyWrongShotErrorDisclosure.aspx

U.S. Department of Veterans Affairs [Root cause analysis tools: VA national center for patient safety]. (2015).