Feedback from an Adverse Event Associated with Medication Error Type Care. Case of the Saint Padre Pio Hospital Centre inLubumbashi in the Democratic Republic of Congo

Abstract

During a recent routine vaccination session for children aged 0 to 11 months at the Padre Pio hospital center in Lubumbashi, a midwife administered twice the dose of the same injectable poliomyelitis vaccine (IPV) to an infant while only one dose was indicated. The child subsequently presented with some digestive disorders such as vomiting and diarrhea that required 24-hour observation in the emergency reception unit. The occurrence of this incident required the holding of a meeting with the various stakeholders. The aim was to examine the possible cause(s) of this incident, to be able to determine whether it was a fault attributable to the vaccinator or whether it was a systemic problem, the aim being to improve the safety of the practice of vaccination by preventing the occurrence of similar situations.