After En Chu Kong Hospital in New Taipei City on Monday last week administered doses of the Pfizer-BioNTech vaccine without diluting it as required, the Central Epidemic Command Center fined the hospital and suspended its right to administer vaccines.
The New Taipei City Department of Health is to review the vaccination procedure and discuss whether the 25 people who received wrong doses need an additional shot.
Although 11 of the 13 recipients who agreed to being hospitalized for observation have been discharged and things are now under control, members of the public are beginning to ask who is accountable for the mistake.
Studies have shown that medication errors are the most common medical error, occurring 3.7 to 16.6 percent of the time. Mistakes can occur at any stage of the process.
The hospital told a news conference that the mistake was made due to negligence during the handover between the pharmacist and the nurse.
Human error being the cause of the incident inevitably leads the public to call for the individuals involved to be held responsible.
However, to prevent similar incidents from happening and to ensure safety with regards to medication, the systemic factors leading to errors by pharmacists and nurses should be reviewed.
Medical staff have been working hard on the front lines to fight the COVID-19 pandemic and protect the public. Since the introduction of COVID-19 vaccines in Taiwan, in addition to administering the shots at their hospitals or clinics, pharmacists and nurses must also support large-scale vaccination stations set up in local communities.
However, there are different COVID-19 vaccine brands, and people receiving the shots are categorized in many groups.
All these factors cause problems that can easily lead to systemic medication errors.
Each time a nurse is assigned a different vaccine, they have to handle it differently. Each vaccine has its own storage requirements and pre-administration procedures.
The Pfizer-BioNTech vaccine is perhaps the one with the most stringent storage conditions, and the pre-administration procedure has 10 separate steps.
To fight the pandemic, most nurses are doing more work than what is normally required of them. This means that they might not be familiar with the work environment or procedures they are assigned to, or even the team members they are working with. These factors increase the possibility of systemic error.
Medical errors are an important issue everywhere in the world, and making mistakes is human nature. As a large number of people are getting vaccinated, a certain number of errors will inevitably occur.
After the incident in New Taipei City, the hospital immediately initiated a procedure to handle the situation and made a public apology.
The city’s health department launched an investigation and is aiming to improve vaccination procedures, as well as monitoring and auditing mechanisms.
Regardless of whether the error caused any harm, the focus should be on how to prevent a similar incident from happening again. To ensure safe administration of vaccines, those who made the mistake should not be personally held accountable.
Medical staff are human beings, not gods. Please do not thank them publicly while exposing them to a witch hunt.
Chen Ching-min is a professor at National Cheng Kung University’s Department of Nursing.
Translated by Lin Lee-kai
There is a modern roadway stretching from central Hargeisa, the capital of Somaliland in the Horn of Africa, to the partially recognized state’s Egal International Airport. Emblazoned on a gold plaque marking the road’s inauguration in July last year, just below the flags of Somaliland and the Republic of China (ROC), is the road’s official name: “Taiwan Avenue.” The first phase of construction of the upgraded road, with new sidewalks and a modern drainage system to reduce flooding, was 70 percent funded by Taipei, which contributed US$1.85 million. That is a relatively modest sum for the effect on international perception, and
At the end of last year, a diplomatic development with consequences reaching well beyond the regional level emerged. Israeli Prime Minister Benjamin Netanyahu declared Israel’s recognition of Somaliland as a sovereign state, paving the way for political, economic and strategic cooperation with the African nation. The diplomatic breakthrough yields, above all, substantial and tangible benefits for the two countries, enhancing Somaliland’s international posture, with a state prepared to champion its bid for broader legitimacy. With Israel’s support, Somaliland might also benefit from the expertise of Israeli companies in fields such as mineral exploration and water management, as underscored by Israeli Minister of
Chile has elected a new government that has the opportunity to take a fresh look at some key aspects of foreign economic policy, mainly a greater focus on Asia, including Taiwan. Still, in the great scheme of things, Chile is a small nation in Latin America, compared with giants such as Brazil and Mexico, or other major markets such as Colombia and Argentina. So why should Taiwan pay much attention to the new administration? Because the victory of Chilean president-elect Jose Antonio Kast, a right-of-center politician, can be seen as confirming that the continent is undergoing one of its periodic political shifts,
On Sunday, elite free solo climber Alex Honnold — famous worldwide for scaling sheer rock faces without ropes — climbed Taipei 101, once the world’s tallest building and still the most recognizable symbol of Taiwan’s modern identity. Widespread media coverage not only promoted Taiwan, but also saw the Republic of China (ROC) flag fluttering beside the building, breaking through China’s political constraints on Taiwan. That visual impact did not happen by accident. Credit belongs to Taipei 101 chairwoman Janet Chia (賈永婕), who reportedly took the extra step of replacing surrounding flags with the ROC flag ahead of the climb. Just
RSS