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
A failure by the Chinese Communist Party (CCP) to respond to Israel’s brilliant 12-day (June 12-23) bombing and special operations war against Iran, topped by US President Donald Trump’s ordering the June 21 bombing of Iranian deep underground nuclear weapons fuel processing sites, has been noted by some as demonstrating a profound lack of resolve, even “impotence,” by China. However, this would be a dangerous underestimation of CCP ambitions and its broader and more profound military response to the Trump Administration — a challenge that includes an acceleration of its strategies to assist nuclear proxy states, and developing a wide array
Twenty-four Chinese Nationalist Party (KMT) lawmakers are facing recall votes on Saturday, prompting nearly all KMT officials and lawmakers to rally their supporters over the past weekend, urging them to vote “no” in a bid to retain their seats and preserve the KMT’s majority in the Legislative Yuan. The Democratic Progressive Party (DPP), which had largely kept its distance from the civic recall campaigns, earlier this month instructed its officials and staff to support the recall groups in a final push to protect the nation. The justification for the recalls has increasingly been framed as a “resistance” movement against China and
Jaw Shaw-kong (趙少康), former chairman of Broadcasting Corp of China and leader of the “blue fighters,” recently announced that he had canned his trip to east Africa, and he would stay in Taiwan for the recall vote on Saturday. He added that he hoped “his friends in the blue camp would follow his lead.” His statement is quite interesting for a few reasons. Jaw had been criticized following media reports that he would be traveling in east Africa during the recall vote. While he decided to stay in Taiwan after drawing a lot of flak, his hesitation says it all: If
Saturday is the day of the first batch of recall votes primarily targeting lawmakers of the Chinese Nationalist Party (KMT). The scale of the recall drive far outstrips the expectations from when the idea was mooted in January by Democratic Progressive Party (DPP) caucus whip Ker Chien-ming (柯建銘). The mass recall effort is reminiscent of the Sunflower movement protests against the then-KMT government’s non-transparent attempts to push through a controversial cross-strait service trade agreement in 2014. That movement, initiated by students, civic groups and non-governmental organizations, included student-led protesters occupying the main legislative chamber for three weeks. The two movements are linked
RSS