Government chapter 9 quizlet

Government chapter 9 quizlet DEFAULT

Vaccine Storage and Handling

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This chapter provides an overview of best practices for vaccine storage and handling. CDC’s Vaccine Storage and Handling Toolkit contains detailed information on best practices and recommendations. Participants in the Vaccines for Children (VFC) program or providers with vaccines purchased with public funds should consult their state or local immunization program to ensure all state storage and handling requirements are met, since there may be requirements that are specific to or tailored to the jurisdiction.

Vaccine Cold Chain

A cold chain is a temperature-controlled supply chain that includes all vaccine-related equipment and procedures. The cold chain begins with the cold storage unit at the manufacturing plant, extends to the transport and delivery of the vaccine and proper storage at the provider facility, and ends with administration of the vaccine to the patient.

Manufacturers, distributors, public health staff, and health care providers share responsibility to ensure the vaccine cold chain is maintained from the time vaccines are manufactured until they are administered.

Vaccine Storage and Handling Standard Operating Procedures (SOPs)

Facilities should develop and maintain clearly written, detailed, and up-to-date storage and handling standard operating procedures (SOPs). SOPs should be reviewed by all staff and updated by the vaccine coordinator annually.

SOPs should contain plans and information for three major areas:

  • General information – include contact information for vaccine manufacturers, equipment service providers, and important facility staff, as well as job descriptions, regularly used forms, and staff training requirements.
  • Routine storage and handling – include information for all aspects of vaccine inventory management, from ordering to monitoring storage conditions.
  • Emergency vaccine storage, handling, and transport – outline steps to be taken in the event of equipment malfunctions, power failures, natural disasters, or other emergencies that might compromise vaccine storage conditions.

VFC providers or those who have vaccines purchased with public funds should contact their immunization program for guidance regarding routine and emergency SOPs.

Staff Training

All staff members who receive deliveries or handle vaccines should be trained in proper storage and handling as described in the facility’s SOPs. SOPs should be kept near vaccine storage units and staff should know where to find them.

Storage and handling training should be done:

  • As part of new employee orientation
  • Annually as a refresher for all staff involved in immunization activities
  • When new vaccines are added to inventory
  • When vaccine recommendations are updated

Vaccine Coordinator

A primary vaccine coordinator should be responsible for ensuring all vaccines are stored and handled correctly, with an alternate coordinator appointed who can serve in the absence of the primary coordinator. These individuals should be fully trained in routine and emergency policies and procedures. Coordinator responsibilities may be completed by the coordinator or delegated to appropriate staff. The coordinator must ensure the delegate has documented training demonstrating competency for the specific tasks assigned and must confirm that tasks are completed.

Some coordinator responsibilities include:

  • Ordering vaccines
  • Overseeing proper receipt and storage of vaccine deliveries
  • Documenting vaccine inventory information
  • Organizing and monitoring vaccines within storage units, including rotating stock and removing expired vaccines
  • Setting up temperature monitoring devices (TMDs) and recording daily temperatures
  • Responding to temperature excursions (out-of-range temperatures) and equipment failures
  • Overseeing vaccine transport (when necessary)
  • Overseeing emergency preparations
  • Creating and updating storage and handling SOPs

Vaccine Storage and Temperature Monitoring Equipment

It is important for a facility to have proper storage and monitoring equipment that is set up correctly, maintained appropriately, and repaired as needed. This equipment protects patients from inadvertently receiving compromised vaccine and protects facilities against costs of revaccinating patients, replacing expensive vaccines, and losing patient confidence.

Refrigerators and Freezers

CDC recommends the following types of refrigerators and freezers:

  • Purpose-built or pharmaceutical-grade units designed to either refrigerate or freeze biologics, including vaccines, are preferred. These units can be compact, under-the-counter style or large units.
  • If a purpose-built or pharmaceutical-grade unit is not available, a stand-alone, household-grade unit may be an acceptable option in some practice settings. Only the refrigerator compartment of a household-grade combination refrigerator/freezer unit should be used. The freezer compartment of this type of unit is not recommended for storing vaccines and there may be areas of the refrigerated compartment that should not be used as well. These units have cold spots and temperature fluctuations, and air circulating from the freezer could expose refrigerated vaccines to freezing temperatures. A separate freezer unit is necessary for storage for facilities that stock frozen vaccines.

All units should have enough space to store the largest inventory expected at the busiest point in the year (e.g., flu season) without crowding.

Never store any vaccine in a dormitory-style or bar-style combined unit. These units often have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines, even when used for temporary storage.

Temperature Monitoring Devices (TMDs)

Every vaccine storage unit must have a reliable TMD. CDC recommends (and VFC requires) the use of a continuous monitoring and recording device called a “digital data logger” (DDL), set at recording intervals of at least every 30 minutes. Many DDLs use a buffered temperature probe. Temperatures measured by a buffered probe match vaccine temperature more closely than those measured by standard thermometers, which tend instead to reflect air temperature. DDLs provide details on how long a unit has been operating outside the recommended temperature range (a temperature excursion). Each DDL should have a current and valid Certificate of Calibration Testing (also known as a “Report of Calibration”) to ensure device accuracy.

DDLs should have the following characteristics:

  • Detachable probe that best reflects vaccine temperatures (e.g., a probe buffered with glycol, glass beads, sand, or Teflon®)
  • Alarm for out-of-range temperatures
  • Low-battery indicator
  • Current, minimum, and maximum temperature display
  • Recommended uncertainty of +/°C (+/-1°F)
  • Logging interval (or reading rate) that can be programmed by the user to measure and record temperatures at least every 30 minutes

Temperature data from a DDL can be downloaded to a computer using special software or retrieved from a website for user review, which is critical to ensuring vaccine safety. The software or website may also allow the user to set the frequency of temperature readings.

Each facility should have a recommended TMD for:

  • Each vaccine storage unit
  • Each emergency transport unit
  • Backup (with a different calibration testing schedule) in case a primary device malfunctions or is out for calibration testing

Calibration testing should be done every one to two years or according to the manufacturer’s suggested timeline. CDC recommends that a DDL’s current and valid Certificate of Calibration Testing include:

  • Model/device name or number
  • Serial number
  • Date of calibration (report or issue date)
  • Confirmation that the instrument passed testing (or instrument in tolerance)
  • Recommended uncertainty of +/°C (+/-1°F) or less

Storage Unit Setup

Storage units should be placed in a well-ventilated room, leaving space between the unit, ceiling, and any wall. Nothing should block the cover of the motor compartment. The unit should be firm and level, with the bottom of the unit above the floor. The unit door should open and close smoothly and fit squarely against the body of the unit. Studies find that most units work best when placed in an area with standard indoor room temperatures, usually considered to be between 20°C and 25°C (68°F and 77°F). Check the manufacturer-supplied owner’s manual for additional guidance on placement and spacing.

Stabilizing Temperatures

It may take two to seven days to stabilize the temperature in a newly installed or repaired refrigerator and two to three days to stabilize the temperature for a freezer.

Befoe using a unit for vaccine storage, the minimum and maximum temperatures each workday for two to seven days should be checked and recorded. If temperatures cannot be recorded digitally, they should be checked and recorded a minimum of two times each workday. Once two consecutive days of temperatures have been recorded within the recommended range, the unit is stable and ready for use.

Power Supply

To protect the storage unit’s power supply:

  • Plug in only one storage unit per electrical outlet.
  • Use a safety-lock plug or an outlet cover to prevent the unit from being unplugged.
  • Post “DO NOT UNPLUG” warning signs at outlets and on storage units to alert staff, custodians, electricians, and other workers not to unplug units.
  • Label fuses and circuit breakers to alert people not to turn off power to storage units.
  • Use caution when using power outlets that can be tripped or switched off and avoid using built-in circuit switches (that may have reset buttons), outlets activated by a wall switch, and multioutlet power strips.

Equipment Maintenance

Storage units and temperature monitoring devices need regular maintenance to ensure proper operation, maintain required temperatures, and extend the useful life of the equipment.

  • Check storage unit door seals regularly for signs of wear and tear.
  • Check door hinges and adjust so that the door opens and closes smoothly and fits squarely against the body of the unit. Leaving the door open can cause the thermostat to respond to warmer room temperatures, and the unit will work harder to maintain the correct temperature inside. The temperature may become very cold in some parts of the unit. Using an open-door alarm and a self-closing door may be helpful.
  • Clean unit coils and motor per manufacturer instructions.
  • Clean inside of units to discourage bacterial and fungal growth. Cleaning must be done quickly to minimize the risk of the temperature going out of range.
  • Defrost manual-defrost freezers when the frost exceeds either 1 cm or per the manufacturer’s suggested limit. Follow the manufacturer’s instructions. While defrosting, store vaccines temporarily in another unit with appropriate freezer temperatures.
  • Temperature monitoring devices experience “drift” over time that affects accuracy. If calibration testing indicates the device is no longer accurate within +/°C (+/-1°F), it should be replaced. Adjustments to correct accuracy are not recommended.
  • Storage unit temperatures may need to be adjusted over time. Temperature adjustments should only be made by a vaccine coordinator and not during a busy part of the workday when the door is being frequently opened. The coordinator should confirm there is not another issue (e.g., unit unplugged, door left open, broken TMD, etc.) before making any adjustment to the temperature.
  • If you believe there could be an issue with the TMD, use the backup TMD to confirm the temperature before making any adjustments.

If a backup generator is used, it should be tested quarterly and serviced annually, and according to the manufacturer’s guidance.

Organizing and Storing Vaccine in Storage Unit

Manufacturers’ package inserts should be referred to for the most up-to-date storage and handling recommendations for specific vaccines and diluents.

Storing Vaccine

To confirm vaccines are stored correctly and to minimize the risk of administration errors:

  • Store vaccines in their original packaging with lids closed in separate containers until ready for administration to protect them from light and provide additional thermal stability/protection. Never store loose vials or manufacturer-filled syringes outside of their packaging. This increases the risk of administration errors, exposes vaccine to light, and makes it more difficult to track expiration dates and manage inventory. For certain purpose-built units, it is recommended that vaccine be stored outside of the packaging. If this is the case, follow the manufacturer’s guidance for vaccine storage.
  • Place vaccines and diluents with the earliest expiration dates in front of those with later expiration dates.
  • Store vaccines and diluents with similar packaging or names or with pediatric and adult formulations on different shelves.
  • Whenever possible, store diluent with the corresponding refrigerated vaccine. Never store diluent in a freezer.
  • Position vaccines and diluents two to three inches from the unit walls, ceiling, floor, and door.
  • Arrange vaccines and diluents in rows and allow space between them to promote air circulation.
  • If using a household-grade unit, avoid storing vaccines and diluents in any part of the unit that may not provide stable temperatures or sufficient air flow, such as directly under cooling vents; in deli, fruit, or vegetable drawers; or on refrigerator door shelves.
  • Place water bottles on the top shelf, the floor, and in the door racks of a household-grade unit. Putting water bottles in the unit can help maintain stable temperatures. (Water bottles are not recommended for use with certain pharmaceutical-grade units, follow manufacturer’s directions.)
  • Avoid placing or storing any items other than vaccines, diluents, and water bottles inside storage units. If other medications and biological products must be stored in the same unit as vaccines, they must be clearly marked and stored in separate containers or bins from vaccines. Potentially contaminated items (e.g., blood, urine, stool) should be properly contained and stored below vaccines to avoid contamination from drips or leaks.
  • Place the TMD in the center of the unit with the vaccines surrounding it. A DDL should be set to measure temperature no less frequently than every 30 minutes.

Temperature Ranges

Refrigerators should maintain temperatures between 2°C and 8°C (36°F and 46°F). Freezers should maintain temperatures between °C and °C (°F and +5°F). Refrigerator or freezer thermostats should be set at the factory-set or midpoint temperature, which will decrease the likelihood of temperature excursions.

Thermostats are marked in various ways and, in general, show levels of coldness rather than temperatures. The only way to know the temperature where vaccines are stored is to measure and monitor it with a TMD.

Monitoring Vaccine Temperatures

To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using a TMD that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday).

A temperature monitoring log sheet should be placed on each storage unit door (or nearby), and the following information should be recorded:

  • Minimum/maximum temperature (or current temperature if using a device that does not record minimum/maximum temperatures)
  • Date
  • Time
  • Name of person who checked and recorded the temperature
  • Any actions taken if a temperature excursion occurred

If a reading is missed, leave a blank entry in the log. Such entries should be distinguished from entries in which the TMD failed to display a reading.

Check unit doors throughout the day and always at the end of the day to ensure they are tightly closed.

On a weekly basis, review storage unit temperature readings for changes in temperature trends that might require action (adjusting unit temperature or repairing/replacing storage or temperature monitoring equipment). Temperature data should be kept for three years (unless state statutes or rules require a longer period).

Temperature Excursions (Out-of-Range Temperatures)

Any temperature reading outside ranges recommended in the vaccine manufacturers’ package inserts is considered a temperature excursion and requires immediate action:

  1. Notify the primary or alternate vaccine coordinator immediately or report the problem to a supervisor.
  2. Label exposed vaccines “DO NOT USE,” and place them in a separate container apart from other vaccines in the storage unit (do not discard these vaccines).
  3. The vaccine coordinator or supervisor should begin to document details of the event.
  4. Implement your facility’s SOPs for temperature excursions, being sure to check temperature monitoring device placement or adjusting unit temperature as needed.
  5. Contact your immunization program and/or the vaccine manufacturer(s) per your SOPs for guidance.
  6. Complete documentation of the event, including actions taken and results.

Vaccines should never remain in a nonfunctioning unit for an extended period. If it is believed a unit has failed, implementation of emergency SOPs should begin.

Vaccine Inventory Management

It is important to make sure vaccines are unpacked and stored correctly and to account for every dose received and used, whether administered, wasted, compromised, expired, or transferred.

Deliveries

Scheduling and Receiving Deliveries

The vaccine coordinator or alternate should be notified immediately when vaccines arrive. Vaccines should be unpacked and stored immediately. Vaccine delivery should only be scheduled on dates and during times staff will be present. A vaccine delivery container should never be left unattended.

Unpacking Deliveries

Vaccines and diluents should be unpacked and promptly stored at recommended temperatures. They should not be stored in an unopened shipment box.

  • Examine the shipping container and contents for signs of damage.
  • Compare contents against the packing list. For frozen vaccines, the packing list may show the maximum time vaccines can be in transit based on shipment date.
  • Ensure that lyophilized vaccines came with the correct type and quantity of diluents.
  • Check vaccine and diluent expiration dates to ensure there are no expired or soon-to-expire products.
  • If included, check the cold chain monitor (CCM) for any temperature excursion during transit. Note: CCMs are for one-time use and should be discarded after being checked.

If there are discrepancies between the contents and the packing list or other concerns about the contents (including temperature excursion), the vaccine manufacturer should be immediately notified. If a temperature excursion is suspected, vaccines should be labeled “DO NOT USE” and stored in the appropriate vaccine storage unit, separated from other vaccines, until a vaccine viability determination is made. The state or local immunization program should be contacted regarding any VFC or other vaccines purchased with public funds.

Inventory Accounting

Conduct a vaccine inventory assessment at least once a month and before placing vaccine orders to ensure adequate vaccines and diluents are on hand. Determining factors for ordering include projected demand, storage capacity, and current vaccine supplies. Many state and local immunization information systems (IISs) have vaccine inventory accounting functions and VFC providers may be required to use the IIS to track inventory.

Stock Rotation and Removal

Vaccine stock should be rotated and checked for expired doses regularly. Any expired vaccines and diluents should be removed immediately to avoid inadvertently administering them.

Understanding Expiration Dates

Determining when a vaccine or diluent expires is an essential step in proper vaccine storage and handling. Administration of expired vaccine remains one of the top vaccine storage and handling errors, so it is crucial for staff to understand how to read expiration dates to prevent patients from receiving invalid vaccine doses.

When the expiration date has only a month and year, the product may be used up to and including the last day of that month. If a day is included with the month and year, the product may only be used through the end of that day. Products that have been contaminated or compromised should not be used, regardless of the expiration date.

In some instances, such as when a manufacturer indicates there is a beyond-use date (BUD), vaccines must be used before the expiration date on the label.

The BUD is calculated based on the date the vial is first punctured and the storage information in the package insert. If the vaccine has no BUD, the vaccine should be used by the expiration date indicated by the manufacturer.

The BUD replaces the expiration date and should be noted on the label, along with the initials of the person making the calculation. Examples include:

  • Reconstituted vaccines have a limited time frame for use once the vaccine is mixed with a diluent.  For example, if the package insert states that the reconstituted vaccine must be used within 30 minutes, it must be discarded if not used by that time. This time frame might only apply as long as the reconstituted vaccine is still in the vial, not after it is drawn into a syringe, so the package insert should be carefully checked.
  • Multidose vials (MDVs) might have a specified time frame for use once they have been entered with a needle. For example, the package insert may state that the vaccine must be discarded 28 days after it is entered. If the vial is entered on June 1, , the BUD is June 29,
  • Manufacturer-shortened expiration dates may apply when vaccine is exposed to inappropriate storage conditions. The manufacturer might determine that the vaccine can still be used but will expire on an earlier date than the date on the label.

In addition to a BUD, some MDVs have a specific number of doses that can be withdrawn. Once the maximum number of doses has been removed, the vial should be discarded, even if there is residual vaccine in the vial.

Vaccine and Equipment Disposal

Sometimes unused vaccine and diluent doses, unopened vials, expired vials, and potentially compromised vaccine may be returned for credit, even if they must be discarded. The state or local immunization program or the vaccine manufacturer can provide vaccine-specific information.

Open and broken vials and syringes, manufacturer-filled syringes that have been activated, and vaccines predrawn by providers cannot be returned and should be discarded according to state requirements.

Immediately after use, all syringe/needle devices should be placed in biohazard containers that are closable, puncture-resistant, leakproof on sides and bottom, and labeled or color-coded. This practice helps prevent accidental needlesticks and reuse. Used needles should not be recapped, cut, or detached from syringes before disposal.

Empty, expired, or compromised vaccine vials are usually not considered hazardous or pharmaceutical waste and do not require disposal in a biomedical waste container. However, state requirements regarding disposal should be followed. Medical waste disposal requirements are set by state environmental agencies.

Predrawing Vaccines

Vaccines should be drawn up only at the time of administration. General-use syringes are designed for immediate administration, not for storage. Contamination and growth of microorganisms can occur in syringes with predrawn vaccine that does not contain a preservative. In addition, vaccine components may interact with polymers in a plastic syringe over time, potentially reducing vaccine potency. Predrawing vaccines can also result in vaccine waste.

Even for off-site clinics, vaccine manufacturers do not recommend predrawing vaccines. As an alternative, CDC recommends using manufacturer-filled syringes (MFSs) for large vaccination clinics.

If vaccines must be predrawn:

  • Set up a separate administration station for each vaccine type to prevent medication errors.
  • Draw up vaccines only after arriving at the clinic site or mass vaccination event.
  • Each person administering vaccines should draw up no more than one MDV or 10 doses at one time.
  • Monitor patient flow to avoid drawing up unnecessary doses.
  • Predraw reconstituted vaccine into a syringe only when ready for administration.
  • If a predrawn vaccine is not used within 30 minutes of being reconstituted, follow manufacturer guidance for storage conditions and time limits.

Any remaining vaccine in predrawn syringes should be discarded at the end of the workday. Predrawn, reconstituted vaccine should never be transferred back into a vial for storage.

Vaccine Transport

To protect the vaccine supply, vaccine should be delivered directly to the facility where it will be used. However, sometimes, vaccine needs to be transported to an off-site or satellite facility for an event like an on-site vaccination clinic. Transport may also be required during emergencies such as long-term power outages or flooding or other natural disasters that can put the vaccine supply in jeopardy. In these instances, certain actions must be taken to protect the vaccine supply.

Vaccine transport to off-site or satellite facilities is different from both shipping and emergency transport. Shipping usually involves a professional carrier and a long distance and time frame for moving vaccines between locations. Transport involves the movement of vaccine over a short time frame and distance between providers. Depending on the situation, transport recommendations may vary. An organization’s SOPs should clearly define transport procedures for all possible scenarios and should be used by trained staff for any vaccine transport.

Preparing Vaccine for Transport

A facility should have a supply of materials needed for transport of the largest annual vaccine inventory.

Container DescriptionEmergency TransportTransport to Off-Site Clinic or Satellite Facility or for Relocation of   Stock
Portable Vaccine Refrigerator or FreezerYesYes
Qualified Container and PackoutYesYes
Conditioned Water Bottle Transport System pdf icon[2 pages]YesNo
Manufacturer’s Original Shipping ContainerYes

(last resort only)

No
Food/Beverage CoolersNoNo

 

Soft-sided containers specifically engineered for vaccine transport are acceptable (and may be part of a qualified container and packout system). Commercially available soft-sided food or beverage coolers should not be used because most are poorly insulated and likely to be affected by room or outdoor temperatures.

A TMD for each transport container should be used during transport, as well as appropriate coolants and transport materials according to the specific transport system(s) being used.

The same shipping containers the vaccines were initially shipped in may be used for emergency transport as a last resort only.

Partially used vials cannot be transferred between providers or across state lines.

Transport of Refrigerated Vaccines to Off-Site or Satellite Facilities

Best practices for transport include:

  • The total time for transport alone or transport plus clinic workday should be a maximum of 8 hours.
  • Transport diluents with their corresponding vaccines to ensure there are always equal amounts of vaccines and diluents for reconstitution.
  • Transport only the amount of vaccine needed for the workday.
  • If a noncommercial vehicle must be used, place the transport containers in the passenger compartment, not the trunk.

Transport of Vaccines in Emergencies

In addition to the actions outlined above, in an emergency situation:

  • Contact an alternative vaccine storage facility before packing any vaccine to confirm it can accept vaccines for storage.
  • Note any protective measures in place at the time of the event (water bottles, battery-powered TMD, transport to alternative facility, etc.).
  • Only open the vaccine storage unit door when ready to pack vaccine in transport containers or when power has been restored.

If an emergency can be anticipated (e.g., weather event), suspend immunization activities before the onset of emergency conditions to allow adequate time for packing and transport.

Storing Vaccines at the Destination

Immediately upon arrival at the off-site location, vaccines should be stored in an appropriate storage unit with a TMD. Follow recommended guidelines for monitoring and recording storage unit temperatures:

  • If the device displays minimum/maximum temperatures, this information should be checked and recorded.
  • If the device does not display minimum/maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday).

If vaccines cannot be stored in an on-site storage unit, they should be kept in the portable vaccine storage unit using the following guidance:

  • Place a TMD (preferably with a probe in a thermal buffer) as close as possible to the vaccines and check and record temperatures hourly.
  • Keep the container closed as much as possible.

Acknowledgements

The editors would like to acknowledge Jennifer Hamborsky, Beth Hibbs, Ginger Redmon, Donna Weaver, A. Patricia Wodi, and Skip Wolfe for their contributions to this chapter.

Selected References

CDC. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices(ACIP)pdf icon[ pages]. Accessed December 27, and August 12,

CDC. Recommendations and Guidelines: Storage and Handling.

CDC.Vaccine Storage and Handling Toolkit pdf icon[65 pages].

Food and Drug Administration (FDA). Vaccines Licensed for Use in the United Statesexternal icon.

Immunization Action Coalition. Clinic Resources: Storage and Handlingexternal icon.

Top of Page

Sours: https://www.cdc.gov/vaccines/pubs/pinkbook/vac-storage.html

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Ethics chapter 6 quizlet

3. We will then show how the National Communication Association (NCA) Credo for Philosophers often emphasize that ethics is _____, which means that it deals with a person's reasoning about how he or she should act. 2. This paper. 4 Utilitarianism: The Greatest Good for the Greatest Number. 1) assessing the needs and risks that an organization-wide ethics program must address; 2) developing and distributing a code of conduct or ethics; 3) conducting training programs for employees; 4) establishing and maintaining a confidential service to answer employees' questions about ethical issues; 5) making sure personal ethics Flashcards and Study Sets Quizlet. are those whose continued association and resources ae absolutely necessary for a firm's Chapter 6 Review Questions: 3, 5, 10, 11, 15, 16, 17 3. Ethics. Though written more than 2, years ago, it offers the modern reader many valuable insights into human needs and conduct. Topics in this class include. The first 12 cases are presented in a format that asks the reader to solve each dilemma. com makes it easy to get the grade you want! THE PROBLEM. Total Cards. Ch 10 Why should you be moral? Chapter Summary What is philosophy and ethics' relationship to it? Philosophy - philia/sophia -means 'love' or 'friend' of wisdom. 6 x 7. The Sarbanes-Oxley Act helps an organization create an ethical corporate culture. We will then show how the National Communication Association (NCA) Credo for 3 καλόν is a term of admiration applied to what is correct, especially (1) bodies well shaped and works of art or handicraft well made, and (2) actions well done (see 3. 2 Overview • This chapter discusses the morality of the market system as a whole. txt) or read online for free. 1 Why Conduct an Audience Analysis; 5. . In addition, both Philippa Foot and Rosalind Hursthouse have sought to place Virtue Ethics (as discussed in its Aristotelian form in Chapter 3) within a naturalist metaethical framework. 5. Chapter 6 - 20 cards. Psychology. 6 Chapter Resources – Environmental Science. Thomas Hobbes () proposed that a society without rules and laws to govern our actions would be a dreadful place to live. obedience and punishment. The common good is a notion that originated more than 2, years ago in the writings of Plato, Aristotle, and Cicero. A. Gravity. Define corporate social responsibility and explain how organizations are [ty 9. 11 Full PDFs related to this paper. Develop the key components of an ethics policy. Data from living individuals b. – p. Learn faster with spaced repetition. A second criticism of the arguments that free markets can deal with all consumer issues takes aim at the characteristic of the free markets: -the assumption that the consumer is a "rational utility maximiser. Don’t steal. Chapter 11 Globalization and the 6. list stages. Match. Chapter 7 - Corrections. Sep 25, · SUMMARY This chapter examines the concept of an ethics audit as a way to help implement an effective ethics program. Principles of Business Ethics is the theme of this chapter in the Business Ethics volume. ISBN ISBN: Authors: Bonnie F. 2 Three Types of Audience Analysis; 5. PowerPoint Chapter 2 Flashcards | Quizlet Learn powerpoint chapter 2 with free interactive flashcards. What is ethics, and how can it be used for better decision making? What is corporate social responsibility? CHAPTER 12 Decision Making, Creativity, and Ethics Nike's decision to manufacture shoes overseas has prompted critics to claim that it exploits workers in poor countries. As cultural beings, of course we can not stay alone and need to ascertain relationships with others. Apply an ethical framework to marketing issues. m. 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Introduction. 1. normative b. com. are those whose continued association and resources ae absolutely necessary for a firm's Assessment Questions. com makes it easy to get the grade you want! (Chapter 2) Balanced Scorecard Model (Chapter 3) African Ubuntu Philosophy (Chapter 4) Sustainability Scorecards & 3BL Reporting (Chapter 5) Business Ethics & Corporate Governance Chapter 6) Source: Own observation In the wake of various corporate scandals and amid increasing concern about Corey Chapter 5 - Corey Chapter 1 - Issues and ethics in the helping professions (8th ed) Chapter 6 Vocab. The focus of these lessons is on the development of language skills needed to think, discuss, and write about business ethics. Question Number Answer Level 1 Head Reference for Answer Difficulty 1 b. Quickly memorize the terms, phrases and much more. 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Still invisible, he hears Gandalf and the dwarves arguing; Gandalf is saying that they must go back and 6 Enhancement. com DA: 11 PA: 50 MOZ Rank: 6 Conclusion; 5. 2 Utilitarian Ethics Utilitarian ethics is a normative ethical system that is primarily concerned with the consequences of ethical decisions; therefore it can be described as a teleological theory or consequentialist theory, which are essentially the same thing, both having a notion that the consequence of the act is the most important determinant of the act being moral or not. The family suffers from poverty and a lack of food. This applies to both initial research ethics review (Article 6. Few ethical issues have been as bitterly fought over during the past forty years as abortion, and neither side has had much success in altering the opinions of its opponents. Aug 31, · It develops a definition of business ethics and discusses why it has become an important topic in business education. 1 Romantic or Sexual Relationships with Patients . In this chapter, you will learn about some of the ethical challenges that you may encounter in your professional and academic life, especially when it comes to technical writing. protecting human life, promoting economic justice, pursuing pe…. Correct answers: Women were expected to . are those whose continued association and resources ae absolutely necessary for a firm's Study Flashcards On Law And Ethics Chapter 6 at Cram. business law chapter 6 quiz. 6 Environmentalism. personal ethics Flashcards and Study Sets Quizlet. 7/23/ Accounting Ethics Chapter 6 Flashcards | Quizlet 1/5 Accounting Ethics Chapter 6 Terms in this set (60) In the U. Get solutions Get solutions done loading. Introductory Clinical research can be defined more or less broadly. Table of Contents. EE II. Chapter 6 - Out of the Frying-Pan into the Fire. Finally, the chapter provides a framework for examining business ethics in this text. Chapter 5 Social Responsibility and Managerial Ethics 1) The classical view of organizational social responsibility is that management's only social responsibility is to maximize profits. Chapter 4: Key Ethical Issues within Law Enforcement 4. Summary. 2 Ethical Advice for Nobles and Civil Servants in Ancient China. Because many parents who abuse substances also neglect or abuse their children, it is common for clients in substance abuse treatment to have contact with some part of the child protective services (CPS) system. Perfect for acing essays, tests, and quizzes, as well as for writing lesson plans. and the HMO 1. Research Chapter 7 - 13 cards. Chapter 1 Chapter 2 Chapter 3 Chapter 4 1. Business ethics chapter_3 [1] - copy. the dollars profits earned by the firm. You're about to go for a several-thousand-year-old ride…and Aristotle ain't going to make it easy for you. View Test Prep - Chapter 6 Quiz from BUS at Strayer University, Washington. The Meaning of Ethics and Morals When narrowly defined according to its original use, ethics is a branch of philos-ophy that used to study ideal human behavior and ideal ways of being. It has influenced the shift in ethical thinking away from abstract rules that reinforce a deductive reasoning process. Assessment Questions. Private police are often seen on public land, providing security to access points of adjacent private land. it DA: 23 PA: 39 MOZ Rank: One of the three major ways (crisis management, issue management and risk management) by which business responds to crisis situations. the federal trade commission (FTC) has authority over. Nice work!Ethics Chapter 6. Ethics and Economics Involve Values a. 3 Conducting Audience Analysis; 5. Chapter 10 - Agency Policies and Professional Ethics. During the time that Sue-Ellen Jacobs was editing the "Ethical Dilemmas" column in the Chapter 5: Audience Analysis. Definition. Concerned with determining what is good or valuable for individuals and society at large. When Bilbo emerges, he discovers that he is on the other side of the Misty Mountains; his wanderings inside have taken him through. Foreign Corrupt Practices Act; Under the FCPA, payments lawful under foreign laws are legal. personal beliefs about the worth of an given idea, attitude, custom, or object that set standards that influence behavior. chapter 3 - chapter 3 ethics and law for the medical office key term assessment ethics 1 2 3 4 5 6 7 8 p c k l n j i e 9 10 11 12 13 14 15 16 g a h m fAnswer Key Chapter 5 - Business Ethics | OpenStax. The Patient's Bill of Rights AHA. 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First it focuses on helping students become more seasoned and polished public speakers, and second is its emphasis on ethics in communication. 02d states: “When recommending tax return positions and when preparing or signing a return on which a tax return position is taken, a member should, when relevant, advise the taxpayer regarding potential penalty consequences of such tax return position, and the opportunity, if any, to avoid such penalties chapter 9: opinions on professional self-regulation The Opinions in this chapter are offered as ethics guidance for physicians and are not intended to establish standards of clinical practice or rules of law

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World history chapter 19 review quizlet

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Vaccine Administration

Filling Syringes

Standard medication preparation guidelines should be followed for drawing a dose of vaccine into a syringe. The cap on the top of an unopened vaccine vial functions as a dust cover. However, not all vaccine manufacturers guarantee the tops of unused vials are sterile, and the way the cover over the stopper is removed can potentially contaminate the stopper. Therefore, using friction and a sterile alcohol swab to wipe the stopper may help assure aseptic technique. Alcohol evaporates quickly and will dry while the needle is being prepared for insertion into the vial.

Instilling air into a multidose vial prior to withdrawing a vaccine dose is not necessary. It could cause a “spritz” of vaccine to be lost the next time the vial is entered, which, over time, can decrease the amount of vaccine in the vial and lead to the loss of a dose (e.g., only nine full doses in a dose vial).

Before withdrawing each dose, the vial should be agitated to mix the vaccine thoroughly and obtain a uniform suspension. The vaccine should be visually inspected for discoloration and precipitation or to see if it cannot be resuspended before administration. If problems are noted, the vaccine should not be administered.

When filling a syringe:

  • Never enter a vial with a previously used syringe or needle.
  • Never mix different vaccine products in the same syringe.
  • Never transfer vaccine from one syringe to another.
  • Never combine partial doses from separate vials to obtain a full dose.

Once the syringe is filled, label it with the name of the vaccine in the syringe. Often more than one vaccine is administered at the same visit and, once drawn into a syringe, vaccines look similar. By labeling the syringe, health care providers will know the route to use to administer the vaccine correctly.

Predrawing Vaccine

Vaccines should be drawn just before administration. However, while MFSs are recommended for large vaccination clinics, there may be rare instances when the only option is to predraw vaccine for off-site clinics.

Procedural Pain Management

Vaccinations are the most common source of procedural pain for healthy children and can be a stressful experience for persons of any age. It has been estimated that up to 25% of adults have a fear of needles, with most needle fears developing during childhood. If not addressed, these fears can have long-term effects such as preprocedural anxiety and avoidance of needed health care throughout a person’s lifetime. Fear of injections and needlestick pain are often cited as reasons why children and adults refuse vaccines.

Pain is a subjective phenomenon influenced by multiple factors, including an individual’s age, anxiety level, previous health care experiences, and culture. Although pain from vaccination is to some extent unavoidable, there are some things that parents and health care providers can do to help. Evidence-based pharmacologic, physical, and psychological interventions exist to ease the pain associated with injections. Combining the interventions described below has been shown to improve pain relief.

Inject Vaccines Rapidly Without Aspiration

Aspiration is not recommended before administering a vaccine. Aspiration prior to injection and injecting medication slowly are practices that have not been evaluated scientifically. Aspiration was originally recommended for theoretical safety reasons and injecting medication slowly was thought to decrease pain from sudden distention of muscle tissue. Aspiration can increase pain because of the combined effects of a longer needle-dwelling time in the tissues and shearing action (wiggling) of the needle. There are no reports of any person being injured because of failure to aspirate.

The veins and arteries within reach of a needle in the anatomic areas recommended for vaccination are too small to allow an intravenous push of vaccine without blowing out the vessel. A study from Canada compared infants’ pain response using slow injection, aspiration, and slow withdrawal with another group using rapid injection, no aspiration, and rapid withdrawal. Based on behavioral and visual pain scales, the group that received the vaccine rapidly without aspiration experienced less pain. No immediate adverse events were reported with either injection technique.

Inject Vaccines that Cause the Most Pain Last

Many persons receive two or more injections at the same clinical visit. Some vaccines cause more pain than others during the injection. Because pain can increase with each injection, the order in which vaccines are injected matters. Some vaccines cause a painful or stinging sensation when injected; examples include measles, mumps, and rubella; pneumococcal conjugate; and human papillomavirus vaccines. Injecting the most painful vaccine last when multiple injections are being administered can decrease the pain associated with the injections.

Breastfeed Children Age 2 Years or Younger During Vaccine Injections

Mothers who are breastfeeding should be encouraged to breastfeed children age 2 years or younger before, during, and after vaccination. Several aspects of breastfeeding are thought to decrease pain by multiple mechanisms: being held by the parent, feeling skin-to-skin contact, suckling, being distracted, and ingesting breast milk. Potential adverse events such as gagging or spitting up have not been reported. Alternatives to breastfeeding include bottle-feeding with expressed breast milk or formula throughout the procedure, which simulates aspects of breastfeeding.

Give a Sweet-Tasting Solution to Children Who Are Not Breastfed

Children (age 2 years or younger) who are not breastfed during vaccination may be given a sweet-tasting solution such as sucrose or glucose one to two minutes before the injection. The analgesic effect can last for up to 10 minutes following administration and can mitigate vaccine injection pain. Parents should be counseled that sweet-tasting liquids should only be used for the management of pain associated with a procedure such as an injection and not as a comfort measure at home.

Pain Relievers

Topical anesthetics block transmission of pain signals from the skin. They decrease the pain as the needle penetrates the skin and reduce the underlying muscle spasm, particularly when more than one injection is administered. These products should be used only for the ages recommended and as directed by the manufacturer. Because using topical anesthetics may require additional time, some planning by the healthcare provider and parent may be needed. Topical anesthetics can be applied during the usual clinic waiting times, or before the patient arrives at the clinic provided parents and patients have been shown how to use them appropriately. There is no evidence that topical anesthetics have an adverse effect on the vaccine immune response.

The prophylactic use of antipyretics (e.g., acetaminophen and ibuprofen) before or at the time of vaccination is not recommended. There is no evidence these will decrease the pain associated with an injection. In addition, some studies have suggested these medications might suppress the immune response to some vaccine antigens.

Follow Age-Appropriate Positioning Best Practices

For both children and adults, the best position and type of comforting technique should be determined by considering the patient’s age, activity level, safety, comfort, and administration route and site. Parents play an important role when infants and children receive vaccines. Parent participation has been shown to increase a child’s comfort and reduce the child’s perception of pain. Holding infants during vaccination reduces acute distress. Skin-to-skin contact for infants up to age 1 month has been demonstrated to reduce acute distress during the procedure.

A parent’s embrace during vaccination offers several benefits. A comforting hold:

  • Avoids frightening children by embracing them rather than overpowering them
  • Allows the health care professional steady control of the limb and the injection site
  • Prevents children from moving their arms and legs during injections
  • Encourages parents to nurture and comfort their child

A combination of interventions, holding during the injection along with patting or rocking after the injection, is recommended for children up to age 3 years. Parents should understand proper positioning and holding for infants and young children. Parents should hold the child in a comfortable position, so that one or more limbs are exposed for injections.

Research shows that children age 3 years or older are less fearful and experience less pain when receiving an injection if they are sitting up rather than lying down. The exact mechanism behind this phenomenon is unknown. It may be that the child’s anxiety level is reduced, which, in turn, reduces the child’s perception of pain.

Tactile Stimulation

Moderate tactile stimulation (rubbing or stroking the skin) near the injection site before and during the injection process may decrease pain in children age 4 years or older and in adults. The mechanism for this is thought to be that the sensation of touch competes with the feeling of pain from the injection and, thereby, results in less pain.

Route and Site for Vaccination

The recommended route and site for each vaccine are based on clinical trials, practical experience, and theoretical considerations. There are five routes used to administer vaccines. Deviation from the recommended route may reduce vaccine efficacy or increase local adverse reactions. Some vaccine doses are not valid if administered using the wrong route, and revaccination is recommended.

Oral Route (PO)

Oral vaccines should generally be administered before injectable vaccines. Rotavirus vaccines (RV1 [Rotarix], RV5 [RotaTeq]) are administered orally. Because the two brands of rotavirus vaccine are prepared differently and have different types of oral applicators, health care professionals should be familiar with how to prepare and administer the brand stocked in their facility. Rotavirus vaccine should never be injected.

To administer rotavirus vaccine:

  • Perform proper hand hygiene. In the setting of the COVID pandemic, gloves should be worn.
  • Administer the liquid vaccine slowly against the inside of the infant’s cheek (between the cheek and gum) toward the back of the infant’s mouth. Never administer the vaccine directly into the throat. This can increase the chance that the infant will cough or gag and spit out the vaccine rather than swallowing it.
  • Allow the infant time to swallow.
  • Care should be taken to avoid triggering the gag reflex.

An infant can eat or drink immediately before or after administration of either product. The dose does not need to be repeated if an infant regurgitates, spits out the vaccine, or vomits during or after administration. No data exist on the benefits or risks associated with readministering a dose of rotavirus vaccine. The infant should receive the remaining recommended doses of rotavirus vaccine following the routine schedule.

Intranasal Route (NAS)

Live, attenuated influenza (LAIV [FluMist]) vaccine is administered by the intranasal route. LAIV is administered into each nostril using a manufacturer-filled nasal sprayer. A dose-divider clip, located on the plunger, separates the total vaccine dose of mL into two equal parts of mL each. LAIV should never be injected. The patient should be seated in an upright position and instructed to breathe normally. The provider should gently place a hand behind the patient’s head to prevent inadvertent movement.

To administer the vaccine:

  • Perform proper hand hygiene. In the setting of the COVID pandemic, gloves should be worn.
  • Remove the rubber tip of the nasal sprayer and place the tip of the applicator just inside the patient’s nostril.
  • Push the plunger rapidly in a single motion until the dose-divider clip is reached.
  • Pinch and remove the dose-divider clip.
  • Place the tip of the applicator just inside the other nostril and repeat the process to administer the remaining vaccine.

Figure 1: image of needle entering Fatty (subcutaneous) tissue, at 45 degree angle, through the dermis, stopping before the muscle tissue. by Lynne Larson. www.biovisuals.com

Source: Lynne Larson, www.biovisuals.com

The dose does not need to be repeated if the patient coughs, sneezes, or expels the dose in any other way.

Subcutaneous Route (Subcut)

Routinely recommended vaccines administered by subcutaneous injection include MMR (MMR-II), VAR (Varivax), IPV (IPOL), MMRV (ProQuad), and PPSV23 (Pneumovax 23). IPOL and Pneumovax 23 can be administered by intramuscular (IM) or subcutaneous injection.

Subcutaneous injections are administered into the fatty tissue found below the dermis and above muscle tissue. For infants younger than age 12 months, a subcutaneous injection is usually administered into the fatty tissue of the thigh, although the upper outer triceps area of the arm may be used if necessary. For persons age 1 year or older, subcutaneous injections are given in the fatty tissue above the upper outer triceps of the arm.

Sites for Subcutaneous Injection

Figure 2: image of needle entering Fatty (subcutaneous) tissue, at 45 degree angle, through the dermis, stopping before the muscle tissue. by Lynne Larson. www.biovisuals.com

Source: California Department of Public Health

When administering a vaccine subcutaneously:

  • Perform proper hand hygiene.
  • Cleanse the skin with a sterile alcohol swab and allow it to dry.
  • Pinch up the skin and underlying fatty tissue.
  • Insert the needle at a degree angle into the subcutaneous tissue and inject the vaccine. Avoid reaching the muscle.
  • Withdraw the needle.
  • Apply an adhesive bandage to the injection site if there is any bleeding.

Intradermal Injection

No routinely recommend U.S. vaccines are administered by the intradermal route of injection.

Intramuscular Route

Subcutaneous Administration Technique

images of injection in arm of toddler and youth

Source: California Department of Public Health

Routinely recommended vaccines administered by IM injection include:

  • DT
  • DTaP (Daptacel, Infanrix)
  • DTaP-IPV-HepB (Pediarix)
  • DTaP-IPV/Hib (Pentacel)
  • DTaP-IPV (Kinrix, Quadracel)
  • Hib (PedvaxHIB, ActHIB, Hiberix)
  • HepA (Havrix, Vaqta)
  • HepB (Engerix B, Recombivax HB)
  • HepB-CpG (Heplisav-B)
  • HepA-HepB (Twinrix)
  • HPV (Gardasil 9)
  • IIV (multiple brands)
  • IPV (IPOL)
  • MenACWY (Menactra, MenQuadfi, Menveo)
  • MenB (Bexsero, Trumenba)
  • PCV13 (Prevnar 13)
  • PPSV23 (Pneumovax 23)
  • RZV (Shingrix)
  • Td (Tenivac, Tdvax)
  • Tdap (Adacel, Boostrix)

image of injection through dermis, fatty tissue, into muscle tissue at 90 degree angle

Source: Lynne Larson, www.biovisuals.com

IPOL and Pneumovax 23 can be administered by IM or subcut injection.

IM injections are administered into the muscle through the skin and subcutaneous tissue. There are only two recommended sites for administering vaccines by IM injection:

  • Vastus lateralis muscle in the anterolateral thigh
  • Deltoid muscle in the upper arm

Injection at these sites reduces the chance of involving neural or vascular structures. The preferred site depends on the patient’s age, weight, gender, and the degree of muscle development.

When administering an IM injection:

  • Perform proper hand hygiene.
  • Identify the appropriate landmarks for the site.
  • Cleanse the skin with a sterile alcohol swab and allow it to dry.
  • Spread the skin tight to isolate the muscle. Another acceptable technique for pediatric and geriatric patients is to grasp the tissue and “bunch up” the muscle.
  • Insert the needle at a degree angle and inject the vaccine.
  • Withdraw the needle.
  • Apply an adhesive bandage to the injection site if there is any bleeding.

Site Recommendations for Intramuscular Vaccination

Sites for Intramuscular Injection

images of baby and vastus laterlis muscle and site of the upper and right thigh used for intramuscular injections. image of youth and deltoid muscle site of injection. Lynne Larson: www.biovisuals.com

For both sites, an IM injection ideally should be administered into the middle of the muscle where the muscle tissue is thickest.

Infants (12 Months or Younger)

For most infants, the vastus lateralis muscle in the anterolateral thigh is the recommended site for injection because it provides a large muscle mass. The muscles of the buttock are not used for administration of vaccines in infants and children because of concern about potential injury to the sciatic nerve, which has been well-documented after injection of antimicrobial agents into the buttock. If the gluteal muscle must be used (e.g., because of reduced anatomic site availability), care should be taken to define the anatomic landmarks. A gluteal muscle injection should be administered laterally and superior to a line between the posterior superior iliac spine and the greater trochanter or in the ventrogluteal site, the center of a triangle bound by the anterior superior iliac spine, the tubercle of the iliac crest, and the upper border of the greater trochanter.

Toddlers (1 Year through 2 Years)

For toddlers, the vastus lateralis muscle in the anterolateral thigh is preferred. The deltoid muscle can be used if the muscle mass is adequate.

Intramuscular Administration Technique

images of injection into toddler thigh and adult arm

Source: California Department of Public Health

Children/Adolescents (3 Years through 18 Years)

The deltoid muscle is preferred for children age 3 through 18 years. The vastus lateralis muscle in the anterolateral thigh is an alternative site if the deltoid sites cannot be used.

Adults (19 Years or Older)

For adults, the deltoid muscle is recommended. IM injections are administered at a degree angle to the skin and, for most adult patients, the skin is spread and the tissues are not bunched. It is acceptable in geriatric patients to grasp the tissue and “bunch up” the muscle. As with children and adolescents, the vastus lateralis muscle in the anterolateral thigh is an alternative site if the deltoid sites cannot be used.

Multiple Vaccinations

Children and adults often need more than one vaccine at the same time. Giving more than one vaccine at the same clinical visit is preferred because it helps keep patients up-to-date. Use of combination vaccines can reduce the number of injections. Considerations when administering multiple injections include:

  • Administer each vaccine in a different injection site. Recommended sites (i.e., vastus lateralis and deltoid muscles) have multiple injection sites. Separate injection sites by 1 inch or more, if possible, so that any local reactions can be differentiated.
  • For infants and younger children, if more than two vaccines are being injected into the same limb, the thigh is the preferred site because of the greater muscle mass. For older children and adults, the deltoid muscle can be used for more than one intramuscular injection.
  • Vaccines that are the most reactive and more likely to cause an enhanced injection site reaction (e.g., DTaP, PCV13) should be administered in different limbs, if possible.
  • Vaccines that are known to be painful when injected (e.g., HPV, MMR) should be administered after other vaccines.
  • If both a vaccine and an immune globulin (Ig) preparation are needed (e.g., Td/Tdap and tetanus immune globulin [TIG] or hepatitis B vaccine and hepatitis B immune globulin [HBIG]), administer the vaccine in a separate limb from the immune globulin.

Vaccine and Supply Disposal

Immediately after use, all syringe/needle devices should be placed in biohazard containers that are closable, puncture-resistant, leakproof on sides and bottom, and labeled or color-coded. This practice helps prevent accidental needlestick injury and reuse. Used needles should not be recapped or cut or detached from the syringes before disposal.

Empty or expired vaccine vials are considered medical waste and should be disposed of according to state regulations.

Medical waste disposal requirements are set by state environmental agencies. Contact the state or local immunization program or state environmental agency for guidance.

Patient Care after Vaccine Administration

Health care providers should be knowledgeable about the policies and procedures for identifying and reporting adverse events after vaccination. A vaccine adverse event refers to any medical event that occurs after vaccination which may or may not be related to vaccination. Further assessment is needed to determine if an adverse event is caused by a vaccine. An adverse vaccine reaction is an untoward effect caused by a vaccine.

Managing Acute Reactions after Vaccination

Health care providers should be familiar with strategies to prevent and identify adverse reactions after vaccination. Potential life-threatening adverse reactions that can occur immediately after vaccination are severe allergic reactions and syncope (fainting).

Severe Allergic Reactions

Severe, life-threatening anaphylactic reactions following vaccination are rare. Thorough screening for contraindications and precautions prior to vaccination can often prevent reactions. Health care providers should be familiar with identifying immediate-type allergic reactions. Symptoms of immediate-type allergic reactions can include local or generalized urticaria (hives), angioedema, respiratory compromise due to wheezing or swelling of the throat, hypotension, and shock. Health care providers should be competent in treating these events at the time of vaccine administration. All vaccine providers should be certified in cardiopulmonary resuscitation (CPR) and be skilled in administering epinephrine. Equipment needed for maintaining an airway should be available for immediate use and the provider should be skilled in using the equipment. Providers should also have a plan in place to contact emergency medical services immediately if there’s an anaphylactic reaction to vaccination, and staff members should know their individual roles in the event of an emergency.

Syncope

All health care professionals who administer vaccines to older children, adolescents, and adults should be aware of the potential for syncope after vaccination and the related risk of injury caused by falls. Appropriate measures should be taken to prevent injuries if a patient becomes weak or dizzy or loses consciousness, including:

  • Have the patient seated or lying down for vaccination.
  • Be aware of symptoms that precede fainting (e.g., weakness, dizziness, pallor).
  • Provide supportive care and take appropriate measures to prevent injuries if such symptoms occur.
  • Strongly consider observing patients (seated or lying down) for 15 minutes after vaccination to decrease the risk for injury should they faint.

Reporting an Adverse Event

Health care providers are required by law to report certain adverse events, and encouraged to report other events, following vaccination to the Vaccine Adverse Event Reporting System (VAERS). Details on reporting adverse events after vaccination can be found at https://vaers.hhs.govexternal icon.

Documenting Vaccinations

Accurate and timely documentation can help prevent administration errors and curtail the number and cost of excess vaccine doses. In addition, preventing excess doses of vaccines may decrease the number of adverse reactions. All vaccines administered should be fully documented in the patient’s permanent medical record. Health care providers who administer vaccines covered by the National Vaccine Injury Compensation Program (which include all vaccines listed on the ACIP recommended child and adolescent immunization schedule) are required by law to ensure the permanent medical record of the recipient indicates:

  • Date of administration
  • Vaccine manufacturer
  • Vaccine lot number
  • Name and title of the person who administered the vaccine and the address of the facility where the permanent record will reside
  • The edition date of the VIS distributed and the date it was provided to the patient

Vaccine administration best practices also include documenting the route, dosage, and site. Providers should update a patient’s permanent medical record to reflect any documented episodes of adverse events after vaccination and any serologic test results related to vaccine-preventable diseases (e.g., those for rubella screening or antibody to hepatitis B surface antigen). The patient or parent should be provided with a personal immunization record that includes the vaccination(s) and date administered.

Although there is no national law, it is also important to document when parents or adult patients refuse vaccines despite the vaccine provider’s recommendation. Professional organizations such as the American Academy of Pediatrics and others have developed forms to document when vaccines are refused (https://www.aap.org/en-us/documents/immunization_refusaltovaccinate.pdfpdf iconexternal icon).

By age 2 years, more than 20% of the children in the United States typically have seen more than one health care provider, resulting in scattered paper medical records. IISs are confidential, population-based, computerized information systems that collect and consolidate vaccination data from multiple health care providers. Vaccine providers are strongly encouraged to participate in an IIS, and some states mandate documenting vaccinations in an IIS. Laws regarding using an IIS vary by state or region.

Some states’ IISs use bar-coding technology. Implementation of a 2D bar code on vaccine vials and VISs allows for rapid, accurate, and automatic capture of certain data, including the vaccine product identifier, lot number, expiration date, and VIS edition date using a handheld imaging device or scanner that could populate these fields in an IIS and/or an electronic health record.

Vaccine Administration Errors

The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” A preventable event is one that is due to an error that could be avoided. For example, if a patient receives the wrong drug because of look-alike labels between different products, that is considered a preventable event. Vaccines, like other medications, can be involved in errors. Vaccine administration errors can have many consequences, including inadequate immunological protection, possible injury to the patient, cost, inconvenience, and reduced confidence in the health care delivery system.

Common vaccine administration errors include:

  • Doses administered too early (e.g., before the minimum age or interval)
  • Wrong vaccine (e.g., Tdap instead of DTaP)
  • Wrong dosage (e.g., pediatric formulation of hepatitis B vaccine administered to an adult)
  • Wrong route (e.g., MMR given by IM injection)
  • Vaccine administered outside the approved age range
  • Expired vaccine or diluent administered
  • Improperly stored vaccine administered
  • Vaccine administered to a patient with a contraindication
  • Wrong diluent used to reconstitute the vaccine or only the diluent was administered

Traditionally, medication errors are thought to be caused by mistakes. This “blame-seeking” approach fails to address the root cause, potentially causing the error to recur. An environment that values the reporting and investigation of errors (and “near misses”) as part of risk management and quality improvement should be established. Health care personnel should be encouraged to report errors and trust that the situation and those involved will be treated fairly without fear of punishment and ridicule. Error reporting provides opportunities to discover how the errors occur and to share ideas to prevent or reduce those errors in the future. When a vaccine administration error occurs, health care providers should determine how it happened and put strategies in place to prevent it in the future.

Guidance for handling some common vaccine administration errors is included in ACIP’s General Best Practice Guidelines for Immunization. Some vaccine administration errors require revaccination, but others do not.

Vaccine administration errors requiring revaccination include:

  • Hepatitis B vaccine administered by any route other than IM injection, or in adults at any site other than the deltoid or anterolateral thigh
  • HPV vaccine that is administered by any route other than IM injection
  • Influenza vaccine administered subcutaneously
  • Any vaccination using less than the appropriate dose (e.g., pediatric formulation hepatitis A vaccine given to an adult) does not count and the dose should be repeated according to age unless serologic testing indicates an adequate response has developed (however, if two half-volume formulations of vaccine are administered on the same clinic day, these 2 doses can count as 1 valid dose)
  • If a partial dose of an injectable vaccine is administered because the syringe or needle leaks or the patient jerks away

Vaccine administration errors not requiring revaccination include:

  • Any vaccination using more than the appropriate dose (e.g., DTaP administered to an adult) should be counted if the minimum age and minimum interval have been met
  • Hepatitis A vaccine and meningococcal conjugate vaccine administered by the subcutaneous route, if the minimum age and minimal interval have been met
  • Administering a dose 4 or fewer days earlier than the minimum interval or age is unlikely to have a substantially negative effect on the immune response to that dose. Vaccine doses administered in this 4-day grace period before the minimum interval or age, with a few exceptions, are considered valid. However, state or local mandates might supersede this guideline.
  • MMR, varicella, and MMRV administered by IM injection if the minimum age and minimum interval have been met

Acknowledgements

The editors would like to acknowledge Beth Hibbs and Andrew Kroger for their contributions to this chapter.

Selected References

  • Australian Technical Advisory Group on Immunization (ATAGI)external icon. Australian Immunization Handbook, Australian Government Department of Health. Canberra; Accessed October 11,
  • Canadian Governmentexternal icon. Public Health Agency of Canada. Canadian Immunization Guide. Accessed October 11,
  • CDC. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Accessed October 11,
  • CDC. Injection Safety. Accessed October 11,
  • Cohen M. Medication Errors. 2nd ed. Washington, D.C.: American Pharmacists Association;
  • Harrington J, Logan S, Harwell C, et al. Effective analgesia using physical interventions for infant immunizations. Pediatrics ;(5)–
  • Hibbs B, Miller E, Shi J, et al. Safety of vaccines that have been kept outside of recommended temperatures: Reports to the Vaccine Adverse Event Reporting System (VAERS), Vaccine ;36(4)
  • Hibbs B, Miller E, Shimabukuro T. Centers for Disease Control and Prevention (CDC). Notes from the field: rotavirus vaccine administration errors–United States, MMWR ;63(4)
  • Ipp M, Taddio A, Sam J, et al. Vaccine-related pain: randomized controlled trial of two injection techniques. Arch Dis Child ;92(12)–8.
  • Jacobson R, St Sauver J, Griffin J, et al. How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation. Hum Vaccin Immunother ;16(9)
  • Lynn, P. Clinical Nursing Skills: A Nursing Process Approach. 5th ed. Philadelphia PA: Wolters Kluwer;
  • Occupational Health and Safety Administration. Occupational exposure to bloodborne pathogens: needlesticks and other sharps injuries: Final Rule (29 CFR Part ). Fed Regist ;66(12)–
  • Opel D, Robinson J, Spielvogle H, et al. Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing’ (PIVOT with MI) trial: a protocol for a cluster randomised controlled trial of a clinician vaccine communication intervention. external iconBMJ Open ;10(8):e
  • Moro P, Arana J, Marquez P, et al. Is there any harm in administering extra-doses of vaccine to a person? Excess doses of vaccine reported to the Vaccine Adverse Event Reporting System (VAERS), Vaccine ;37(28)
  • Committee on Identifying and Preventing Medication Errors. Board of Health Care Services: Aspden P, Wolcott J, Bootman J et al., eds. Preventing Medication Errors. Washington DC: National Academies of Sciences;
  • Shimabukuro T, Miller E, Strikas R, et al. Notes from the Field: Vaccine Administration Errors Involving Recombinant Zoster Vaccine – United States, MMWR ;67(20)
  • Smith S, Duell D, Martin, B. Clinical Nursing Skills: Basic to Advanced Skills. 8th ed. Saddle River, NJ: Pearson Education, Inc.;
  • Su J, Miller E, Duffy J, et al. Notes from the Field: Administration Error Involving a Meningococcal Conjugate Vaccine–United States, March 1, September 22, MMWR ;65(6)
  • Suragh T, Hibbs B, Marquez P, et al. Age inappropriate influenza vaccination in infants less than 6 months old, Vaccine ;38(21)
  • Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. Can Med Assc Journal ;
  • Taddio A, Ilersich A, Ipp M, et al. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations systematic review of randomized controlled trials and quasi-randomized controlled trials. Clinical Therapeutics ;31(Suppl 2):S48–S
  • Taddio A, McMurtry C, Shah V, et al. Reducing pain during vaccine injections: clinical practice guideline. CMAI ;(13)–
  • Taylor L, Greeley R, Dinitz-Sklar I, et al. Notes from the Field: Injection Safety and Vaccine Administration Errors at an Employee Influenza Vaccination Clinic—New Jersey, MMWR ;64(49)–4.

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