SNOMED Code in Vaccine Invitations - incorrect vaccination coding
We are writing to inform you of an incident that we have identified regarding the use of SNOMED codes in vaccine invitation batch messages sent via Accurx by some GP practices in England.
Summary of issue
A trend was observed where vaccine administration events were entered into patients’ records held on GP practice clinical systems and were subsequently deleted. Investigation revealed a number of cases where SNOMED codes for actual vaccine administration were included in batch invitation messages and saved to records. The intended action appears to have been to select an invitation SNOMED code, however an administration code was added.
This potentially affects up to 57,000 batch items across 337 practices in England. The investigation suggests that this issue has predominantly impacted some records for RSV vaccination but it may have also impacted smaller numbers of other vaccine types.
While it means individuals have been invited, some individuals who had an administration code recorded but have not been vaccinated will remain unprotected against disease and may not be sent future invites, so this will require timely follow up.
All practices are requested to record any instances of patient harm resulting from missed vaccinations using the Learn from Patient Safety Events (LFPSE) system. This is essential for monitoring, learning, and improving patient safety across the NHS.
Actions being taken:
- Accurx is sending the attached (pdf) communication to affected GP practices today. It summarises the issue and actions to be taken.
Action for ICBs
- On the back of the communication to affected practices from Accurx, ICBs should send a follow up communication to their affected GP practices within 24 hours, with additional actions. The communication includes a table for each affected GP practice to send back to ICB leads by Friday 29th August. The tables returned to ICBs by practices should be collated and sent to the NHSE SPOC Team (england.london-covid19voc@nhs.net) by Friday 12th September. The communication also includes a template for GP practices to send to PCSE if they have patients with an inaccurate vaccination record who have moved practice.
- NHSE has engaged with the ICO and is also writing directly to GP Data Protection Officers (DPOs) to support around potential Information Governance issues.
Additional actions/information for ROC/NHS England regional commissioners:
- As a result of this incident, there may need to be some payment reconciliation. The data and information collected from affected GP practices and collated by ICB will support regional teams in determining whether any payment adjustments are required, in line with the provisions for Managing Public Money, which applies to all public bodies. ICBs should collate information from affected practices, as set out, and send it to the NHSE SPOC Team (england.london-covid19voc@nhs.net). NHSE SPOC to send the collation onto NHS Regional Operations Centre (ROC) contact, copied to the NHSE regional commissioning team. The collated regional response should be sent from ROC to National Operations Centre (NOC) by Friday 19th September.
Thank you for your support with this.