Erroneous vaccine reconstitution

Very important topic. We are aware of cases that have happened in busy municipal post partum units (muscle relaxant was used for family planning) in South Asia. In general there is a dedicated staff (a Public Health Nurse who supervises the Cold Chain point and does not permit medicines in the ILR. Orientations and trainings for these staff and the less literate cold chain handlers are done every 2 or 3 years. One issue that works the opposite way is that these gatekeepers refuse to allow Anti snake Venom in the ILR. This results in it being kept outside the Cold Chain or in the Deep Freezer (have personally corrected and photographed the latter problem once)

Prabir - good points! Ideal is, of course, if the vaccines and diluents can be kept in a separate fridge, so that the erroneous mixing become much less likely. However, I think in many, many health facilities, there is only one fridge, and health workers are hard pressed to keep all temperature-sensitive meds in there - who can blame them? But this increases the risk of possible mix-up. I was thinking more along the line of a colour-coding, maybe a "red" container for non-vaccine products and a "blue" container for vaccines. But this again may make the packing in the fridge more difficult.... Any thoughts?

Visual stock management and organization sounds like a powerful approach. I haven't seen much of it first-hand in any global health setting so far. Kenya seems to be using boxes to organize its vaccines, but not sure where the diluents go. Beyond avoiding deadly confusion as Rudi suggests, it can be a powerful inventory management tool especially at health facilities. Ideally all the product of a kind are in a box so risk of loss and misplacement is reduced, time to find product and identify stock out is also reduced. Additionally, it is possible to use 2-compartment bin with a sort of visual safety stock to encourage replenishment to happen before the products runs out completely. Btw, such practice is very common and considered best practice in developed world retailers and pharmacies. These are many advantages that definitely would make usage of bins to organize stock in bins in the fridge an intervention to try. Additional visuals, color coding, etc are all powerful cues for better management as well. The main challenge from using bins in a fridge is the possibly poor usage of limited storage space. This can be limited if the bins are small enough such that you can remove some the empty ones from the fridge. Probably one wants a written sign on them or some color stickers. Some grouping of products in a same bins could be considered as well to make packing more efficient; for example to put diluents together separately from all dangerous substance. Expanding the thread a little, I'd be curious of examples of settings where bin systems have been used at health facility level to learn from this experience. Yann

Colour coding of boxes storing drugs and vaccines is a good suggestion, Infact in some of the districts we work in, we had similar problem. Vaccines and muscle relaxants stored together. This inspite that we had recent episodes of mixups leading to programmtic errors. We had to really convince the staff and medical officers to store the vaccines and other drugs separately. The ILR used to store the drugs/anti snake venom etc was marked as "for storing drugs" and removed from the cold chain room for vaccines. Government of India is also planning to introduce bundling for vaccines requiring reconstitution.

Thank you, Yann, Karan and Ganbaatar for your insights. The actual experience in India mentioned by Karan was interesting: this issue was seen as sufficiently dangerous to in fact have invested in two separate fridges... like Ganbaatar, I was also thinking along the line of label colours, to make vaccines and their associated diluents stand out, but this would require a major input and exercise in standardization by vaccine manufacturers. Another basic solution may be joining the vaccine and the diluent phyically - already there are some vaccines on the market where the two vials are joined by a clip, making it - hopefully - near impossible to reconstitute the vaccine with the wrong diluent. Do you have any there other experiences with this problem, or new solutions?