An analysis of clinical risks in vaccine transportation.

'Cold chain' transport is an integral part of a system of vaccine transportation that assures the potency of vaccines. If the temperature of vaccines is not kept between the ranges of 2 and 8 degrees C, this can lead to adverse effects especially for the recipients of first time immunization, as no protection is offered. This investigation has shown that there is considerable risk of vaccines being rendered impotent due to ad hoc collection of vaccines by healthcare professionals from pharmacy services, outside of the cold chain transport agreement with the vaccine supplier. This is because at present there are no guidelines for ad hoc collection of either vaccines or the approved cold chain equipment provided to transport the vaccine. The root cause analysis has shown that the general practice can manage this risk by making changes to its system for vaccine ordering, stock control and maintenance. A number of changes are proposed, including the appointment of a vaccine coordinator and the development of a protocol for ad hoc collection of vaccines from pharmacy. By focusing on improving the quality of the process, the practice can improve the care and safety of its immunization programme.