‘Leave post only after finishing task’: MOH reiterates Covid-19 vaccination protocols after SNEC dose error

• The Health Ministry has told vaccination teams to adhere strictly to protocols, after a lapse resulted in a person being given five doses of the Covid-19 vaccine
• Healthcare workers are given clearly defined roles at vaccination sites, and should leave their positions only when their immediate task has been completed, said Senior Minister of State for Health Janil Puthucheary 
• More healthcare professionals will also be hired and trained so that there will be adequate vaccination staff to prevent overwork 

SINGAPORE — The Ministry of Health (MOH) has directed teams administering Covid-19 vaccines to adhere strictly to protocols — including leaving their positions only when their immediate task is done — to prevent another person from receiving the wrong dosage of the drug, said Senior Minister of State for Health Janil Puthucheary in Parliament on Wednesday (Feb 24). 

Dr Janil was responding to several Members of Parliament (MPs) who asked about the recent lapse during a vaccination exercise at the Singapore National Eye Centre (SNEC), which resulted in a staff member receiving the equivalent of five doses of the Pfizer-BioNTech Covid-19 vaccine in one shot.

The current protocols stipulate that healthcare workers involved in giving vaccines be given clearly defined roles to manage their workload, Dr Janil told the House.

And if they have to step away from their stations, they should properly document and hand over their roles to other staff, and leave their positions only when their immediate task has been completed, he added. 

To ensure those administering vaccines are not overworked, Dr Janil said that more healthcare professionals will be trained and hired “so that there will be adequate staffing to cater for these work-rest cycles and meet service demands”.

HOW THE ERROR HAPPENED

Ms Ng Ling Ling, MP for Ang Mo Kio Group Representation Constituency (GRC), Mr Gerald Giam (Aljunied GRC) and Mr Yip Hon Weng (Yio Chu Kang Single Member Constituency), had asked how the incident happened and how processes will be improved.

SNEC’s vaccination exercise took place on Jan 14, and it announced the error in a statement on Feb 6. 

It attributed the mistake to a communication lapse among the vaccination team at the time.

It said then that the staff in charge of diluting the vaccine had been called away to attend to other matters while preparing vaccines, and a second staff member had mistaken the undiluted dose in the vial to be ready for administering.

The vaccination exercise was stopped immediately and the rest of the SNEC employees were vaccinated at Singapore General Hospital. 

SNEC is not involved in vaccination exercises for any other groups.

The error was discovered within minutes and the affected employee remains well with no adverse reaction or side effects, Dr Janil said.

These effects usually show up within hours or days after the vaccination, he added.

“We are quite assured of the health and comfort status of the staff member affected but we will continue to pay close attention and stay in close touch,” he said.

'VACCINATION TEAMS TRAINED, AUDITED'

Dr Janil told the House that vaccination providers must be familiar with the guidelines, protocols and operational workflows before they begin vaccinations.

Vaccination staff are given clearly written instructions for preparing the vaccines, which must be done in a designated area away from where the injections are given, he said. They must also label whether a vial has been diluted.

MOH conducts periodic audits to ensure that healthcare workers adhere to safety standards. 

An MOH spokesman later confirmed to TODAY that such audits had been in place before the lapse at SNEC.

These audits generally look at the equipment, processes, skill sets of staff and the safety of patients, Dr Janil said in Parliament.

How they are carried out varies significantly depending on where the vaccinations are conducted, but all vaccination sites will be engaged by the authorities, he added.

In response to Mr Giam, who had asked about preventing overwork among vaccination teams, Dr Janil added that vaccination sites have workers not assigned to any station who can relieve their colleagues who need a break.

There will also be other staff members on duty tasked with roving around to watch for incidents and to assist any medical workers who need help, he added.

“I would like to reassure members of this House that MOH continues to place the utmost importance on the safety of our staff and patients in the vaccination process.”