Singapore National Eye Centre worker accidentally given 5 doses of Covid-19 vaccine due to human error

SINGAPORE - A staff member at the Singapore National Eye Centre (SNEC) has been erroneously administered the equivalent of five doses of the Pfizer-BioNTech Covid-19 vaccine.

This occurred during a vaccination exercise on Jan 14, said the SNEC on Saturday (Feb 6).

The error was discovered within minutes of the vaccination, when the staff member was resting in a designated area.

"Senior doctors were alerted immediately and the staff (member) was assessed and found to be well, with no adverse reaction or side effects," said SNEC.

The staff member was warded at the Singapore General Hospital (SGH) for further observation, before being discharged two days later.

The SNEC said it has been following up closely with the worker, who remains well.

As a safety measure, the vaccination exercise at the SNEC was stopped immediately upon detection of the error. The rest of the SNEC staff were vaccinated at SGH. 

"Our investigations showed that it was human error resulting from a lapse in communication among the vaccination team, who had been preparing and administering the injections at that time," said the centre.

It said the worker in charge of diluting the vaccine had been called away to attend to other matters during the preparation of the vaccine.

A second staff member had mistaken the undiluted dose in the vial to be ready for administering.

The SNEC has apologised to the affected staff member and the worker's family, said Professor Wong Tien Yin, who is medical director of the centre.

"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," he added.

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He added that the centre has done a thorough review of its internal processes and taken steps to tighten them so that such lapses do not occur again.

SNEC is not involved in the vaccination exercise for other groups.

As at Tuesday, more than 175,000 people have received their first dose of the Covid-19 vaccine.

About 6,000 people have also taken their second dose of the vaccine and completed the full vaccination regimen.

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This article was first published in The Straits Times. Permission required for reproduction.