Two registered nurses were found to have breached a 15-month-old boy's rights after he was accidentally given the wrong vaccine.
The vaccine he was given, Infranrix-IPV, was not harmful, the Immunisation Advisory Centre said.
The boy's mother took him to his GP for his 15-month immunisations, where he was to receive Act‑HIB, M‑M‑R II and Prevenar 13, said a report by the deputy Health and Disability Commissioner.
A registered nurse took the vaccines from the medical centre's refrigerator before the boy's appointment, but mistakenly took Infranrix-IPV instead of the Act-HIB vaccine.
Infranrix-IPV is listed on the New Zealand National Immunisation Schedule as a booster given at the age of four years, after a child has received all three doses of Infanrix-hexa.
It is used to immunise against diphtheria, tetanus, pertussis, and poliomyelitis.
The nurse asked another registered nurse to check the vaccines, but neither picked up on the mistake.
After giving the vaccines, the nurse looked at the child's computer immunisation record and Well Child book, and realised what had happened.
She excused herself from the room, told her colleagues about the error, and called the regional immunisation coordinator, who told her the vaccine would not be harmful to the child.
The boy's parents later took him to the hospital's emergency room, the report said.
An Emergency Department registrar documented: "[I]rritable post vaccination, no obvious cause ... plan: home with paracetamol [follow-up] with GP."
The first nurse told the Commission she would normally have referred to National Immunisation Schedule card when selecting the vaccines, but there were none at the medical centre that day.
The second nurse was in the middle of a task and was "preoccupied" when she checked over the vaccines.
"Because I was preoccupied I failed to provide my full attention to the vaccines and missed that one of the childhood vaccines was incorrect for the scheduled age. What happened was not usual procedure, it was because I was the only nurse [she] could find at the time. I should have been at the computer to check as we usually would. Unfortunately this caused me to miss [her] mistake," she told the Commission.
Since the incident, the centre has made it a rule that nurses must check the vaccines by referring to the patient's computerised medical record, Well Child book, and the National Immunisation Schedule immunisation card, which must now be available at all times.
The deputy commissioner said the nurses breached the boy's rights not providing services to him with reasonable care and skill.
She recommended that each nurse provide a written apology to the family, and that the medical centre provide training to medical staff on its revised Childhood Immunisation Policy, audit its compliance with the policy, and use this case as an anonymised case study for the education of future staff.