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从一组新生儿免疫错误中学到的经验教训
Loubna Alj1,2, Amina Tebaa3, Ismail Talibi3,4
1Centre Anti Poison et de Pharmacovigilance du Maroc, Ministry of Health and Social Protection, Rue Lamfadel Cherkaoui, Madinate Al Irfane, BP 6671, Rabat, Morocco.
Therapeutic advances in vaccines and immunotherapy
|January 5, 2024
概括
严重的免疫错误发生在六名新生儿接受了罗库而不是乙型肝炎疫苗时,导致一名死亡. 这突显了药物储存和包装中的关键安全问题,需要立即注意,以防止未来的疫苗不良事件.
科学领域:
- 医疗安全 医疗安全
- 药物监督 药物监督 药物监督
- 疫苗学 疫苗学 疫苗学
背景情况:
- 一组涉及新生儿的免疫错误发生在一家大学生产医院 (MUH).
- 六名新生儿无意中接种了罗库,而不是乙型肝炎 (HepB) 疫苗.
- 这起事件导致受影响的新生儿出现呼吸困难,其中一人死亡.
研究的目的:
- 调查这个IE集群的发现.
- 确定错误的潜在原因和贡献因素.
- 提出风险最小化策略,以提高疫苗的安全性.
主要方法:
- 对向摩洛哥药监中心 (MPC) 报告的IE集群进行了描述性分析.
- 一项调查遵循了世界卫生组织的指导.
- 进行了根本原因分析,以确定导致因素.
主要成果:
- 关键因素包括罗库和HepB疫苗的外观相似的包装,首次在MUH接种HepB疫苗,缺乏全职药剂师和不安全的药物储存.
- 在给Sugammadex和转移到新生儿护理后,五名新生儿康复.
- 建议包括意识培训,改善护理程序,药剂师预约和药物储存的重新评估.
结论:
- 报告严重的IE对于确定原因和实施纠正措施至关重要.
- 从这些错误中吸取的教训对于提高全球疫苗安全协议至关重要.
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