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COVID-19 vaccination error: Those involved in process should not step away before completing immediate task, MOH says

COVID-19 vaccination error: Those involved in process should not step away before completing immediate task, MOH says

A general view of the Singapore National Eye Centre (SNEC). (Photo: Google Street View)

SINGAPORE: Healthcare workers who are involved in the COVID-19 vaccination process should leave their positions only after their immediate task has been completed, said Senior Minister of State for Health Janil Puthucheary in Parliament on Wednesday (Feb 24).

“Should there be a need to step away, there must be proper documentation and handing over of roles and duties to other staff members,” he added.

Dr Puthucheary was responding to Member of Parliament (MP) Yip Hon Weng (PAP-Yio Chu Kang), one of three MPs who asked about the incident at the Singapore National Eye Centre (SNEC) when a staff member was wrongly administered the equivalent of five doses of the Pfizer-BioNTech COVID-19 vaccine during a vaccination exercise.

The error was due to a lapse in communication among the vaccination team, Dr Puthucheary said.

READ: Singapore National Eye Centre staff received 5 doses of COVID-19 vaccine due to human error

“They had been preparing and administering the vaccinations at that time. The staff in charge of diluting the vaccine had been called away to attend to other matters during the preparation of the vaccine before the dilution of the doses in that particular vial had been carried out. A second staff member had mistaken the undiluted doses in that vial to be ready for administration,” he said.

SNEC and MOH have also followed up closely with the affected staff member, who remains well with no adverse reaction or side effects, he added.

Mr Yip had asked why there was no dedicated personnel to handle this “critical operation” and “no formal briefing with notes if a handover was necessary”. He also asked if there is a standard operating procedure (SOP) across institutions to handle vaccine preparation and how the SOP will be enhanced to prevent a recurrence of an overdose. 

MP Ng Ling Ling (PAP-Ang Mo Kio) also asked a similar question on SOP at other vaccination sites while MP Gerald Giam (WP-Aljunied) asked how public healthcare institutions manage the workload of medical workers to prevent them from being overworked “so as to avoid human errors of the type which occurred in the Singapore National Eye Centre”.

ROSTERED BREAKS TO ENSURE WORKERS HAVE ENOUGH REST

To ensure that each staff member involved in the vaccination exercise is assigned a manageable workload, there are specific stations within the sites for registration, screening, vaccination, and monitoring, Dr Puthucheary said. He noted that there are “clearly” defined roles undertaken by all employees across the stations.

“Public healthcare institutions have planned rostered breaks and staff rotations so that staff have sufficient rest during and between their shifts. The public healthcare institutions will also continue to train and hire more healthcare professionals, so that there will be adequate staffing to cater for these work-rest cycles and meet service demands,” he said.

In a supplementary question, Mr Giam asked for the recourse and remedies available should medical workers feel "overworked", and how they would be assured that there will be no penalty given on their performance assessments.

READ: Getting more than recommended dose of Pfizer-BioNTech COVID-19 vaccine unlikely to be harmful: MOH

Dr Puthucheary said that there are staff members who are not assigned to a given station who are available to relieve these medical workers. 

He added that there are more staff members than required for a given station "with a specific role of roving around and watching for incidents or the need to step in and assist". 

Mr Yip asked whether authorities will continue to follow up with the affected employee who was given the extra doses for any long-term side effects, and if the employee will continue to receive care for any long-term health issues even after leaving the service.

Dr Puthucheary said that the affected staff member will be given healthcare and will be followed up on "quite closely", but stressed that no known adverse side effects were detected. 

"The nature of adverse effects and side effects from vaccines, is that they are present within hours to days, usually, after a vaccination. So we are quite assured by the health and comfort, the status of the staff member affected," he added. 

Following this incident, as a safety measure, the vaccination exercise at SNEC was stopped immediately and subsequent vaccinations for staff members continued at the Singapore General Hospital, Dr Puthucheary said.

He said that medical protocols are in place at all COVID-19 vaccination sites to ensure the safety of those who are vaccinated and to provide guidance on the management of the vaccination.

“Clear, written instructions on the preparation and administration of the vaccine are used,” he said.

“There is a designated and segregated area for the preparation and administration of the vaccines. There must be clear labelling to differentiate diluted and undiluted vaccine vials. These instructions are disseminated to and used as training materials for the staff involved in the vaccination process.”

He added that to ensure such lapses do not occur again, MOH has instructed vaccination providers to adhere strictly to the protocols.

“All vaccination providers must also undergo training to familiarise themselves with these guidelines, protocols and operational workflow prior to the commencement of their vaccination operations. MOH also conducts periodic audits to ensure that safety standards are adhered to,” he said.

Source: CNA/ja

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