CLEARER guidelines on the administration of vaccines have been recommended in an Eastern Health Board report into the incorrect immunisation of 66 children in Newbridge, Co Kildare a fortnight ago.
The reason for the mistake was failure to check that the correct vaccine was contained in vials to be used in the immunisation clinic set up in St Conleth's primary school, says the report.
The authors conclude that "human error" could be the only reason for the mistake, which resulted in a three-in-one immunisation vaccine being given instead of the correct two-in-one vaccine.
The report of the investigating group, appointed by the board's Chief Executive Officer, recommends tighter safeguards for the packaging and labelling of vaccines.
The health board says it intends to implement the recommendations immediately.
The report says that the Area Medical Officer who administered the wrong vaccine "accepted her error" and had expressed her regret "for the upset caused" to the children involved.
According to the investigating group the Area Medical Officer told them that confusing colour coding and packaging of vaccines had contributed to the error.
It is understood that some board members registered their dissatisfaction with the content of the report at a special meeting of the board last night.
It is believed that some board members expressed the opinion that details in the report made it more likely that the board would face legal action from parents in Newbridge.
The report says that many of the recommendations may need to be "reviewed in the light" of guidelines being drawn up by the National Immunisation Committee.
The mistaken vaccination is described as a "fundamental breach which could result in a loss of the confidence of parents and the public in the childhood immunisation programme".
The Area Medical Officer has been "on leave with pay" pending the carrying out of the investigation. This is said to have no "disciplinary connotations".
The position of the individual involved has yet to be decided the health board.
Representatives of the health board and the parents are due to meet next week