Singapore National Eye Centre staff received 5 doses of COVID-19 vaccine due to human error
SINGAPORE: An employee at the Singapore National Eye Centre (SNEC) was wrongly administered the equivalent of five doses of the Pfizer-BioNTech COVID-19 vaccine due to a human error, the public healthcare institution said on Saturday (Feb 6).
The error happened on Jan 14 during a vaccination exercise conducted at SNEC for its staff members.
“The error was discovered within minutes of the vaccination when the staff was resting in a designated area after vaccination,” said SNEC in a press release.
“Senior doctors were alerted immediately and the staff was assessed and found to be well, with no adverse reaction or side effects.”
READ: Getting more than recommended dose of Pfizer-BioNTech COVID-19 vaccine unlikely to be harmful: MOH
As a precaution, the affected employee was warded at Singapore General Hospital (SGH) for observation.
"The staff’s condition remained stable throughout and the staff was discharged two days later. We have been following up closely with the staff, who remains well," said SNEC.
The vaccination exercise at the eye centre was stopped immediately and the rest of its employees were vaccinated at SGH.
“SNEC is not involved in Singapore’s vaccination exercise for any other groups,” it said.
According to SNEC, investigations showed that it was a human error resulting from a lapse in communication among the vaccination team at the time.
“The staff in charge of diluting the vaccine had been called away to attend to other matters during the preparation of the vaccine, and a second staff member had mistaken the undiluted dose in the vial to be ready for administering,” said SNEC.
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The eye centre has done a “thorough review” of its internal processes and has taken steps to ensure that such lapses do not happen again, said SNEC’s medical director Professor Wong Tien Yin, apologising for the incident.
“SNEC takes a very serious view of this incident. The safety of those receiving the vaccination during our staff vaccination exercise is of our utmost priority. We are extremely sorry that this incident happened,” he said.
“We have apologised to the staff concerned and the staff’s family. We will continue to monitor the staff’s health closely and provide the necessary support.”
In response to CNA's queries, the Ministry of Health (MOH) said clinical trial data from Pfizer-BioNTech has indicated that receiving more than the recommended dose of the Pfizer-BioNTech COVID-19 vaccine is unlikely to be harmful.
MOH added that the incident at SNEC is an isolated one, and that it has not been notified of any similar incidents at other vaccination sites.
SNEC told CNA that the affected employee remains well and is scheduled for the second dosage of the vaccine, pending the blood serology test results.
READ: Singapore starts vaccinating seniors against COVID-19 with pilot exercises in Tanjong Pagar, Ang Mo Kio
Singapore started vaccinating its first healthcare worker on Dec 30 in a small-scale test run at the National Centre for Infectious Diseases.
The vaccination exercise was then rolled out to other healthcare institutions and workers in sectors like aviation and land transport.
Seniors across Singapore will progressively be offered the vaccine from mid-February.