When vaccination administration goes wrong and how to avoid it
Dr Mark Woodrow, MBBS, MBA, GDipAppLaw, GCertArts, EMCert(ACEM), MACLM, General Manager – Medical Advisory Services, Avant
Wednesday, 16 September 2020
A resurgence of participation in seasonal influenza vaccination due to COVID-19, means an accompanied increase in adverse events. While some discomfort for a few days is to be expected, and occasional fevers and significant swelling can occur, no one would expect to have disabling shoulder pain for months or years.
Avant has managed over 200 matters in the past five years in relation to vaccine administration. These usually involve administration of the wrong vaccine or dose, concerns about sterility, predictable side-effects, consent or family custody issues.
Patient demands compensation
A 29-year-old mother of three*, presented to her GP for an unrelated issue. It was recommended that she undergo annual influenza vaccination, to which she gladly consented. The vaccination was administered into her dominant left shoulder without apparent incident.
That night, she began to experience pain in her shoulder, significantly limiting her movement. She visited the practice the next day, but the original GP was unavailable so she saw his colleague, who advised her that the injection site was too high. He prescribed paracetamol and oxycodone.
Two days later, the pain had progressed, and she had little movement. Concerned about septic arthritis she was referred to the local ED, where infection was considered unlikely. A few days later she underwent ultrasound and cortisone injection.
Despite a further cortisone injection, physiotherapy and eventually surgery, she has been unable to return to her work as a pharmacy technician and formalised a compensation claim.
Vaccine administration issues difficult to defend
Shoulder injury related to vaccine administration (SIRVA) is a rare but recognised complication of vaccinations that is preventable but can have devastating consequences for both the patient and the administrator. In the past three years, this issue has arisen eight times at Avant and has a high probability of leading to a civil claim or regulatory inquiry.
The difficulty in these matters is an injection into the shoulder joint or subacromial space which causes SIRVA is due to technical problems during administration of the vaccination and is hard to defend. All literature supports the notion that the cause of SIRVA is poor technique. While appropriate consent is important to address many of the other issues which predictably can occur with vaccination, even the best consent process will not provide a defence against a technical failure.
The inflammation caused by an inappropriately administered vaccine can have severe and lasting effects due to frozen shoulder or adhesive capsulitis. Other causes include rotator cuff injury, bursitis, tendinopathy or brachial neuritis.
Early management critical
Early recognition and management are critical to minimise injury. Options for treatment include anti-inflammatory medication, physiotherapy, steroid injection or occasionally surgery. Characteristically, significant pain and reduction in shoulder movement starts within a few hours of the vaccination.
It is imperative when administering an injection, to ensure your arm is relaxed by your side and the appropriate needle is aimed slightly down with at least two to three finger breadths below the acromion. Although this is a relatively straightforward procedure, understanding the anatomy, landmarks and technique is essential. The expectation of a few days of discomfort should be conveyed to the patient and they should be encouraged to return for review if they experience prolonged or severe pain, or an inability to move their shoulder.
- Use appropriate systems and checks to ensure the correct vaccination is being given and appropriate consent has been obtained.
- Pay attention to landmarks and technique every time you administer an injection.
- Discuss with patients the expected effects and indications for further review.
For more information, see the Australian Immunisation Handbook.
Complete our eLearning course on the consent process.
- Shoulder injury related to vaccine administration and other injection site events. Bancsi A, Houle SKD, Grindrod, KA. Can Fam Physician. 2019 Jan; 65(1): 40–42.
- Don't Aim Too High: Avoiding Shoulder Injury Related to Vaccine Administration. Cross GB, Moghaddas J, Buttery J, Ayoub S, Korman TM. Aust Fam Physician. 2016 May; 45(5):303-6.
- Risk of Bursitis and Other Injuries and Dysfunctions of the Shoulder Following Vaccinations. L H Martín Arias, R Sanz Fadrique, M Sáinz Gil, M E Salgueiro-Vazquez, 2017, Sep 5;35(37):4870-4876.
- *The scenario in this article is based on Avant claims experience to date. Certain information has been de-identified to preserve privacy and confidentiality.