目的对1例强化免疫麻疹疫苗接种后发生热性惊厥的事件进行调查,明确原因和防范措施。方法对患儿个案调查表和调查诊断报告、住院病例等进行分析。结果高热惊厥史不属于麻疹疫苗禁忌症,接种单位在接种程序上存在失误,在家长不同意接种的情况下实施了接种,确定为一起预防接种差错事件。结论差错事件发生的主要原因是接种单位部分接种流程和程序缺失;其次为未重视和掌握儿童既往健康史,未开展入托接种证查验;其三是接种人员责任意识淡薄。为防范和避免类似事件的发生,对热性惊厥史儿童接种麻疹疫苗,必须严格履行知情同意和告知程序;接种单位应建立健全儿童预防接种信息资料,认真做好托幼机构和学校接种证查验工作;接种人员必须强化责任意识,不得简化工作流程和程序。 Objective To investigate the incidence of febrile seizures in one case of intensive immunization with measles vaccine, and clarify the causes and preventive measures. Methods Children’s case investigation questionnaire and diagnostic reports, inpatient cases were analyzed. Results The history of febrile seizures did not belong to the taboo of measles vaccine. The vaccination unit had some mistakes in vaccination procedures. Inoculation was carried out when the parents did not agree with the vaccination and was confirmed as a vaccination error prevention event. Conclusion The main reason for the occurrence of the error event is the lack of vaccination procedure and procedure. In the second place, the past history of the disease was not valued and mastered. The inoculum vaccination certificate was not carried out. The third was the weak sense of responsibility of vaccinates. In order to prevent and avoid the occurrence of similar incidents, children with history of febrile seizures should be strictly informed of informed consent and informed procedures when vaccinating children with measles; vaccination units should establish and improve information on vaccination of children and conscientiously do nursery school and school vaccination card examination Work; vaccinations staff must strengthen the sense of responsibility, not simplifying the work processes and procedures.