Influences on tetanus immunization in accident and emergency.

We studied the casualty records of 479 patients with open skin injury arriving over 2 single weeks, 3 months apart, to assess adequacy of adherence to protocols for active immunization against tetanus. 234 patients were treated correctly. In 114 cases immunization was insufficient or tetanus was not mentioned at all; in 29 cases immunization was excessive and 102 records were ambiguous and no conclusion could be drawn. There was no evidence in junior doctors' management indicating learning over 3 months but the mention of tetanus by a triage nurse was associated with a highly significant increase in the number of records showing correct treatment. There is a persistent high error rate in tetanus immunoprophylaxis despite a department manual, an induction course, and conspicuously displayed treatment protocols. More individual feedback seems required but the unexpected benefit from assessment by a triage nurse may have greater impact in reducing treatment errors.