Closely following on from previous embarrassing reports of a practice being publicly outed in major press outlets for challenges with vaccine storage and cold chain, comes another breakdown with vaccination procedures, in this case with the incorrect vaccine being given to a child. *
The practice in question had been accredited.
Dr Paul Mara, QPA Managing Director with forty years experience in rural generalist practice, says that the problems identified in recent media are not isolated. Vaccine storage and cold chain and medication management still comprise a significant proportion of areas where standards are not met in general practice.
These are problems that can potentially occur with any practice and they reflect a systemic breakdown in practice processes and a failure of accreditation to provide an in-depth assessment and identify important factors affecting patient safety and quality of care.
“The problem again highlights the issues with the current tick a box, point in time accreditation system when the process is promoted as being simple”, said Dr Mara.
“Whenever an injection is given to any patient, particularly when the pressure is on, as it almost always is in general practice, my experience in rural anaesthetics is that we must stop and confirm on at least three times before we give any patient any injectable medication, by asking the following questions:
Right patient?
Right drug?
Right dose?
Right site?
Right way?”
While the practitioner in question provided open disclosure for this preventable mishap, and there is as yet no indication that the patient suffered or will have any adverse consequences, the reputational damage to the practice was acute and the mother of the child was exposed to considerable stress.
“Quality assurance, meeting standards and accreditation are not simple. It is important that accrediting agencies and surveyors review practice processes in depth during accreditation visits to identify risk areas, protect patients and help practices avoid problems”.
Dr Paul Mara AM MB BS FACRRM FRACGP
Founder and Managing Director, Quality Practice Accreditation
* Subscription required to access the full article that was published in the Sydney Morning Herald on the 16th March 2025