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SINGAPORE – A staff member at the Singapore National Eye Center (SNEC) mistakenly received the equivalent of five doses of the Pfizer-BioNTech Covid-19 vaccine.
This occurred during a vaccination exercise on January 14 and was due to human error resulting from a failure in communication between members of the vaccination team, SNEC said on Saturday (February 6). He said he has been following the staff member closely, who is doing well.
SNEC said the worker in charge of diluting the vaccine had been called in to attend to other business before it was done.
A second staff member had then mixed up the undiluted dose in the vial to be ready for administration.
The error was discovered minutes after vaccination.
“Senior physicians were alerted immediately and staff (member) were evaluated and found to be fine, with no adverse reactions or side effects,” SNEC said.
The worker was kept at Singapore General Hospital (SGH) for further observation, before being released two days later.
As a safety measure, the vaccination exercise at SNEC was stopped immediately after the error was detected and the rest of the staff were vaccinated at SGH.
The center does not participate in the vaccination of other groups.
SNEC has apologized to the affected staff member and the worker’s family, said Professor Wong Tien Yin, the center’s medical director. “SNEC takes this incident very seriously. The safety of those who receive the vaccine during the vaccination exercise of our staff is our highest priority, ”he added.
He said the center has done a thorough review of its internal processes, and has taken steps to toughen them so that such lapses do not occur again.
SNEC told The Straits Times that the worker involved in administering the vaccine injection has been counseled.
On Saturday, the Ministry of Health (MINSA) said it has worked with SNEC to identify the lapses that contributed to the error.
“Pfizer-BioNTech clinical trial data has indicated that receiving more than the recommended dose of the Pfizer-BioNTech Covid-19 vaccine is unlikely to be harmful,” the ministry said. He said no similar incidents have been reported to him at other vaccination sites.
The Health Ministry also said there are strong medical protocols in place at all vaccination sites to ensure the safety of those vaccinated.
“These include protocols for the vaccination processes on dose preparation, dilution and administration of vaccines, including the need for a clear indication to differentiate diluted and undiluted vaccine vials,” he said.
The ministry said that it has since reminded vaccination providers to strictly adhere to the protocols and that it will continue to work with them to ensure maximum safety in the vaccination process.
Infectious disease experts The Straits Times spoke with also said the overdose is unlikely to be harmful. Some noted a similar case in Germany last year, where eight workers in a nursing home received a vaccine overdose but showed no serious adverse effects.
It also won’t cause the worker to contract Covid-19, said Professor Ooi Eng Eong of the Duke-NUS School of Medicine.
But the overdose could amplify common side effects of the vaccine, such as fever and aches and pains.
Some experts also said that the staff member would still need a second dose of the vaccine.
There should be a system in which at least two people check that the correct dose is being administered, said Dr. Leong Hoe Nam of Mount Elizabeth Novena Hospital.
Associate Professor Hsu Li Yang of the NUS Saw Swee Hock School of Public Health said mistakes made during the vaccination campaign are “somehow inevitable” but overdose cases should be extremely rare now that the incident has been highlighted .
“Ultimately, however, errors are reduced with practice and familiarity with procedures,” said Professor Paul Tambyah, president of the Asia-Pacific Society for Clinical Microbiology and Infection.
He said the chances of error are likely to decrease significantly once primary care providers, such as general practitioners, are tasked with doing so, as they would have more experience administering vaccines.
As of last Tuesday, more than 175,000 people had received their first dose of the vaccine. About 6,000 people have also taken their second and last dose.
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