Process Improvement for Submitting Hepatitis B Birth Dose Vaccine to Immunization Registry

The Problem:

As of January of 2014, all immunizations administered to newborns were required by law to be reported to the South Carolina Immunization Registry (IR). However, according to a Joint Commission best practice, there’s a generic naming convention to ensure patient safety for newborns while they are inpatients in the hospital. That generic name is not reconciled with the child’s legal name until discharge. Depending on the electronic health record system a facility uses, this can lead to duplicate entries, error messages and other difficulties in reconciliation.

For Lexington Medical Center, the system sent the message to the IR at the time of administration under an alias name. The alias naming convention required manual reconciliation between the generic name and birth name to update the patient’s immunization record in the electronic health record.  This was performed by the physician practice of the newborn’s primary care provider. This reconciliation process did not correct the original message sent to the IR with the alias name.

For MUSC, the large volume of babies made manual reconciliation impossible.

The Goal:

Both hospitals sought to implement process improvements that would eliminate database errors and improve reporting accuracy to the Immunization Registry.

Method & Implementation:

MUSC was in the process of extending its EPIC system from Ambulatory EMR to Ambulatory and Inpatient EMR, which required overhauling the immunization interface. In order to have the process run smoothly, the system now does a “message retrigger” on a weekly basis that scans the error log for generic baby names and then copies the original entry in the record and puts it back in the queue while clearing the error. The messages are then re-built with the updated name in the database at the time of the retrigger—so if the generic name has been reconciled with the legal name, the message goes out smoothly.

Lexington Medical Center programmed a similar solution, with EPIC holding immunization messages sent to the IR for patients with “boy” or “girl” in the name [the generic names recommended by The Joint Commission] in the error work queue until the legal name overwrites the newborn’s alias. Once that happens, the message becomes eligible for retriggering in the work queue.  


Both hospitals have dramatically improved their accuracy and reporting rates to the IR thanks to these process improvements, although both continue to look at continued improvements to establish additional fail safes and to deal with unusual circumstances, like newborns who are discharged without a legal name.

For more information about this best practice, please contact Agnès Gravrand at MUSC or Sherry Winters at Lexington Medical Center. To tell us about your own best practices, email

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