Two registered nurses at a bustling medical centre combined to "depart from accepted standards of nursing care" and give a 15-month-old boy the wrong vaccine.
According to a ruling issued on Monday by Health & Disability Commissioner Meenal Duggal, on July 14, 2016, Mrs A took her son, Master A, for his 15-month immunisations at a medical centre.
A registered nurse selected the vaccines from the medical centre's refrigerator prior to the child's visit, but mistakenly selected Infanrix-IPV instead of the Act-HIB vaccine.
A second registered nurse was asked to check the vaccines, but failed to spot the error.
Infanrix-IPV was given to the boy and the first registered nurse noticed the mistake when checking the immunisation record and the boy's Well Child Book.
The names of the registered nurses and medical centre were not published, but the ruling said the first registered nurse had been practising for "for many years" and the second "for a few years".
Although administering the wrong vaccine did not harm the child, Ms Duggal says both nurses combined to "depart from accepted standards of nursing care" and "failed to provide Master A services with reasonable care and skill".
While one of the nurses said the medical centre was busy that day, Ms Duggal said by following correct vaccine protocol and re-checking the vaccine selected, the mistake would not have been made.
The second, less-experienced nurse, says she "should never have accepted that responsibility in that instance".
One of the nurses said correct procedures were now followed "vehemently".
Ms Duggal said the appropriate response was a written apology to the child's mother by both nurses, extra training on immunisation policies and an audit on the medical centre's vaccination procedures to be carried out in the coming months.