Child gets wrong vaccine twice, Cambridge-based doctor cautioned, appeal board document shows
A stock image of a doctor.
Published Friday, June 7, 2019 2:57PM EDT
A doctor at a Cambridge clinic has been cautioned by the College of Physicians and Surgeons of Ontario after a child was given the same wrong vaccine twice.
A document from the Health Professions Appeal and Review Board dated June 3 indicates that a complainant, referred to as SM, brought a young patient to the clinic on Dec. 15, 2017 for a meningitis vaccine.
A physician at the clinic saw the patient and gave them a Menjugate C vaccine instead.
The document shows that SM was notified of the mistake by Public Health and returned four days later to tell the clinic that the patient got the wrong vaccine.
“The other physician, who had administered the vaccine, consulted with a paediatrician colleague and Public Health and was advised there was no concern and the patient could receive the correct Men C ACYW135 [meningitis] vaccine in four to six weeks,” background information in the decision shows.
When SM returned on Jan. 20, 2018, documents show that a second doctor, the family medicine practitioner, referred to only as ST MD in the document, saw the patient and once again administered the incorrect Menjugate C vaccine.
“When the Applicant learned the purpose of the visit was to receive a meningitis vaccine, she encouraged the Respondent to attend at her family doctor’s practice but the Respondent advised it was too far,” ST MD maintained in a response dated March 29, 2018.
ST MD maintained that she had no indication that SM had brought the patient to the clinic before.
“The Committee investigated the complaint and decided to to[sic.] require the Applicant to attend at the College to be cautioned in person with respect to proceeding with treatment without having a patient’s chart available,” the review board document says in part.
It says the doctor was also told to write a two- to four-page report about vaccines from birth to the age of 15 with respect to the Canadian names for them.
According to the document, the doctor requested that the appeal and review board review the committee’s decision.
“With regard to the Applicant’s second argument, the Applicant argued that because there were no adverse side effects or harm to the patient nor complications arising out of her administration of the incorrect vaccine there was no demonstrated risk of harm to the public,” the review board document says.
Waterloo Region Public Health says that extra vaccination does not usually result in injury.
“If an extra vaccine is administered in error there are typically no associated harms reported outside of enhanced reaction at the injection point,” explains Julie Kalbfleisch with Public Health.
She also says that, while there are safety protocols in place to prevent wrongful vaccinations, they do happen occasionally.
Ultimately, the review board confirmed the decision for the doctor to be cautioned in person and to take no further action.
It also noted that a caution isn’t a sanction, but an opportunity to educate the physician in their future practice.